Columbia  ^ntiierjSfttj) 


lAdtttna  Htbrarg 


DISEASES  OF  CHILDREN 


BY 


EDWIN  E.  GRAHAM,  A.B.,  M.D. 

PROFESSOR    OF    DISEASES    OF   CHILDREN   IN   THE    JEFFERSON  MEDICAL    COLLEGE;    PEDIATRIST 

TO  THE  JEFFERSON  MEDICAL  COLLEGE  HOSPITAL  AND  TO  THE  PHILADELPHIA  GENERAL 

HOSPITAL,  PHILADELPHIA;    CONSULTING  PEDIATRIST  TO  THE  TRAINING  SCHOOL 

FOR  THE   FEEBLE-MINDED  AT  VINELAND,   N.   J. ;   MEMBER    OF   THE 

AMERICAN  PEDIATRIC  SOCIETY,   ETC. 


HUustrateD  wttb  S9  engravings  anD  4  Iplatcs 


LEA  &   FEBIGER 

PHILADELPHIA  AND   NEW   YORK 
1916 


V ); ,/, 


Vv 


Entered  according  to  the  Act  of  Congress,  in  the  year  1916,  by 

LEA  &   FEBIGER, 
in  the  Office  of  the  Librarian  of  Congress.    AH  rights  reserved. 


TO 

THE    MEMORY    OF    MY 

BROTHER 

JAMES  graham;  m.d. 


^v 


PREFACE. 


In  the  preparation  of  this  work  the  aim  of  the  author  has  been  to 
make  it  represent  the  most  modern  views  upon  each  subject  discussed, 
and  to  present  these  views  in  such  a  way  that  they  may  be  immediately 
available  to  the  busy  practitioner  as  well  as  easily  intelligible  to  the 
medical  student. 

The  treatment  of  each  disease  is  given  in  full,  and  the  physician 
engaged  in  general  practice  will  find  herein  the  precise  management  of 
a  typical  case  of  any  disease  which  he  is -called  upon  to  treat.  In 
addition,  the  clinical  examination  of  the  sick  child  is  carefully  con- 
sidered, and  its  anatomy  and  physiology  are  discussed  in  detail. 

In  the  consideration  of  each  subject  a  special  effort  has  been  made 
to  make  the  book  thoroughly  up  to  date,  and  to  each  chapter  has  been 
allotted  the  amount  of  space  its  importance  appeared  to  warrant, 
only  a  few  of  the  rarest  diseases  having  been  omitted.  As,  however, 
the  book  has  been  written  from  the  practical,  and  not  from  the  theo- 
retical standpoint,  recent|and  unconfirmed  suggestions  and  theories 
have  not,  -as  a  rule,  been  considered. 

Sufficient  space  has  been  devoted  to  pathology,  and  a  larger  amount, 
proportionately,  to  symptoms,  diagnosis,  and  treatment.  The  illus- 
trations and  ar-ray  plates  are  all  from  the  author's  private  and  hospital 
cases,  except  where  credit  has  been  given  to  others. 

From  long  experience  in  teaching  both  students  and  practitioners,  it 
has  seemed  to  the  author  most  important  that  the  processes  of  normal 
digestion  be  thoroughly  understood  before  any  attempt  be  made  to 
study  the  various  disturbances  and  diseases  of  the  gastro-intestinal 
tract,  hence  the  subject  of  normal  digestion  has  been  considered  in  a 
special  chapter. 

The  subject  of  infant  feeding  has  received  particular  attention; 
the  construction  of  milk  mixtures,  usually  a  vague  subject  to  both  the 
general  practitioner  and  the  student,  is  carefully  explained,  and  the 
calculation  of  caloric  and  percentage  feeding  has  been  illustrated  by 
formulas  reduced  to  ounces. 


vi  PREFACE 

Diseases  of  the  gastro-intestinal  tract  have  been  presented  in  full,  and 
some  of  the  most  advanced  ideas  concerning  diagnosis  and  treatment 
have  been  incorporated.  Food  injm-ies,  chronic  constipation,  pyloro- 
spasm,  and  pyloric  stenosis  have  received  special  consideration,  a 
careful  differentiation  being  made  between  the  two  latter  affections. 

Special  features  of  the  book  to  which  the  author  desires  to  call  the 
attention  of  the  reader  are  the  chapters  on  Infant  Mortality,  Heredity 
and  Environment,  Puberty,  Fresh  Air,  and  Diseases  of  the  Liver, 
Spleen,  and  Thymus  Gland.  To  each  of  these  subjects  is  allotted  a 
special  chapter  in  view  of  their  ever-increasing  importance  to  the 
practising  physician. 

The  Diseases  of  the  Nervous  System  have  been  discussed  in  eighty 
pages.  A  careful  consideration  of  these  diseases  belongs  in  a  book  on 
Pediatrics,  and  the  physician  interested  in  children  will  find  here  a 
broad  field  for  study.  To  Infantile  Paralysis  the  author  has  devoted 
ten  of  these  pages. 

A  special  chapter  has  been  devoted  to  Dentition,  for  the  author 
regards  this  as  a  normal  and  physiological  process  in  the  com-se  of 
normal  development.  Particular  attention  is  also  called  to  the  articles 
on  Diphtheria,  Influenza,  Pertussis,  Poliomyelitis,  and  Enlargement 
of  the  Thymus  Gland. 

The  author  here  acknowdedges  his  indebtedness  to  the  following 
physicians  connected  with  the  Pediatric  Department  at  Jefferson 
Medical  College:  Dr.  Julius  Blechschmidt,  Dr.  R.  L.  Engle,  Dr. 
Joseph  Fleitas,  and  Dr.  W.  H.  Johnston. 

I  wish  to  express  my  appreciation  to  my  publishers,  Messrs.  Lea  & 
Febiger,  for  their  earnest  cooperation  during  the  entire  period  of  the 

book's  preparation. 

E.  E.  G. 
Philadelphia,  1916. 


'V 


CONTENTS 


CHAPTER  I. 


The  Normal  Infant  at  Birth. 

General  Appearance 17 

Circulatory  System 18 

Digestive  System 19 

Respiratory  System 20 

Ductless  Glands ■ 20 

Genito-urinary  System 20 

Nervous  System 21 

Mammary  Glands 21 

Temperajture 21 

Care  of  the  Newborn 21 

Bathing 21 

Clothing 22 

Sleep  .      .      .   ■ 23 

Exercise   .      .      . ~ 24 

Fresh  Air 25 

Vaccination 27 

i 


CHAPTER  II. 

Normal  Development  of  the  Child. 

Height        ..'.... 30 

Weight 30 

Head 34 

Neck    . 35 

Spine 35 

Thymus  Gland 35 

Thorax 36 

Fetal  Circulation 37 

Pulse 39 

Respiration 39 

Temperature 40 

Muscular  Development 41 

Nervous  System 42 

Special  Senses 43 

Stomach 44 

Intestine 45 


viii  .        CONTENTS 

CHAPTER  III. 

The  Clinical  Examination  of  Sick  Children. 

Family  History ' 46 

Inspection ...  46 

Palpation 47 

Auscultation 48 

Percussion 49 

Mensuration ■ 49 

CHAPTER  IV. 

Infant  Mortality. 

General  Statistics 50 

CHAPTER  V. 

Heredity 68 

CHAPTER  VI. 

Congenital  Malformations. 

Brain  and  Spinal  Cord 72 

Meningocele 72 

Encephalocele -74 

Hydrencephalocele • 74 

Acute  Hydrocephalus _ 75 

Chronic  External  Hydrocephalus 75 

Chronic  Internal  Hydrocephalus 75 

Caput  Succedaneum 78 

Cephalhematoma : 78 

Anencephalia 80 

Hare-hp  and  Cleft  Palate 82 

Hare-Up 82 

Cleft  Palate 84 

Congenital  Malformations  of  the  Tongue        85 

Tongue-tie 85 

Macroglossia 86 

Ranula 86 

Congenital  Diseases  of  the  Neck 86 

Fistulse  of  the  Neck 86 

Congenital  Cystic  Lymphangioma  of  the  Neck 87 

Congenital  Torticollis 87 

Congenital  MaKormations  of  the  Esophagus 88 

Meckel's  Diverticulum 88 

Hernia  of  the  Umbilical  Cord .  90 

Umbilical  Hernia 90 


CONTENTS  IX 

Congenital  Dilatation  of  the  Colon 92 

Atresia  of  the  Bowel 93 

Malposition  of  the  Bowel      •     -=\ 95 

Exstrophy  of  the  Bladder     . 96 

Undescended  Testes;  Cryptorchidism 97 

Hydrocele 98 

Congenital  Hydrocele 98 

Hydrocele  of  the  Tunica  Vaginalis      . 98 

Encysted  Hydrocele  of  the  Cord 98 

Obliteration  of  the  Bile  Ducts 99 

Spina  Bifida 100 

Spinal  Meningocele 100 

Myelomeningocele 101 

Myelocystocele 101 

Spina  Bifida  Occulta 101 

Atresia  of  the  Vagina,  Labia,  and  Urethra 103 

Hypospadias  and  Epispadias 104 


CHAPTER  VII. 

Diseases  of  the  Newborn. 

Prenatai  Paralysis 105 

Natal  paralysis _    .      .  106 

Birth  Palsies   . 108 

Erb's  Palsy  {Obstetric  Paralysis) 108 

Klumpke's  Palsy ~ 110 

Facial  Palsy Ill 

Albuminuria  and  Uric  Acid  Infarction Ill 

Bone  Injuries 112 

Asphyxia  of  the  Newborn 112 

Asphyxia  Cyanotica 113 

Asphyxia  Pallida 113 

Atelectasis 115 

Mastitis    ' 117 

Icterus  Neonatorum 118 

Acute  Septic  Infection  of  the  Newborn 120 

Diseases  of  the  Umbilicus 124 

Omphahtis 124 

Gangrene  of  the  Cord 125 

Gangrene  of  the  Umbilicus 125 

Umbilical  Hemorrhage 125 

Hemorrhage  in  the  Newborn 126 

Hemorrhagic  Disease  of  the  Newborn 126 

Acute  Fatty  Degeneration  of  the  Newborn  (Buhl's  Disease)  ....  128 

Epidemic  Hemoglobinuria  (Winckel's  Disease) 128 

Melena  Neonatorum 129 

Erysipelas 131 

Tetanus  (Trismus  Neonatorum) 133 

Sclerema 135 

Sclero-edema 136 

Achondroplasia  (Chondrodystrophy— Microlelia) 138 


CONTENTS 


CHAPTER  VIII. 

Infant  Feeding. 

Cow's  Milk 141 

Bacteria  in  Milk 142 

The  Souring  of  Milk 143 

The  Preservation  of  Milk 143 

Sterilization 144 

Pasteurization 145 

Concerning  the  Feeding  of  Sterilized,  Pasteurized,  or  Raw  Milk        .      .  146 

Peptonization 148 

Diluents 149 

Water 149 

Cereal  Diluents ' 149 

Alkaline  Diluents 150 

Condensed  Milk 150 

The  Food  Materials  Used  in  Infant  Feeding 151 

Water 153 

Protein 154 

Fats    , 155 

Carbohydrates 156 

Mineral  Salts 157 

Breast  Feeding 158 

Mammary  Gland ' 159 

Frequency  of  Breast  Feeding 160 

Human  Milk ■     ...  161 

Advantages  of  Breast  Feeding .  161 

Wet  Nurse 165 

Alexins 166 

Percentage  Feeding 167 

Modification  of  Milk 167 

Calculation  of  Percentages 172 

Amount  of  Cream  in  Milk 173 

Albumin  Milk:  Eweissmilch:  Protein  Milk        .      .      .      .      .      .      .      .  173 

Buttermilk 174 

Whey 175 

Proprietary  Foods 176 

Meat  Preparations 177 

Malt  Soup 178 

Artificial  Feeding 178 

Fats 178 

Carbohydrates 179 

Milk  Sugar 179 

Cane  Suga-r 179 

Starch 179 

Proteins 179 

Caloric  Feeding    .      .     " 179 

Home  Modification  of  Milk 180 

Laboratory  Method  of  Modification  of  Milk .  181 

Feeding  after  the  Weaning  Period 183 

Care  of  Bottles  and  Nipples 183 


CONTENTS  xi 


CHAPTER  IX. 

NormalDigestion. 

The  Oral  Cavity 184 

Gastric  Digestion 185 

Anatomical  and  Physiological  Peculiarities 186 

Absorption  in  the  Stomach 190 

Anatomical  and  Physiological  Peculiarities  of  the  Intestines 190 

Succus  Entericus 192 

Absorption  in  the  Intestines 193 

Bacteria 195 

Fat  Indigestion  . 199 

Carbohydrates 200 

Protein  Indigestion 201 

Disturbance  of  Balance 205 

Dyspepsia 206 

Alimentary  Intoxication       .  -   .      . 207 

Feces 209 

Composition 211 


,  CHAPTER  X. 

Fresh  Air  in  the  Treatment  of  Disease    ....     212 


CHAPTER  XL  , 

Dentition 217 

CHAPTER  XII. 

Rickets. 

General  Considerations 227 

Congenital  Rickets 245 

Adolescent,  or  Late,  Rickets 245 

Acute  Rickets 245 

CHAPTER  XIII. 

Diseases  of  the  Gastro-intestinal  Tract. 

Diseases  of  the  Lips 246 

Herpes 246 

Perleche 247 

Diseases  of  the  Tongue 248 

Geographical  Tongue 248 

Glossitis 248 

Microglossia 249 

Macroglossia 249 


xii  CONTENTS 

Diseases  of  the  Mouth 249 

Alveolar  Abscess 249 

Ulcer  of  the  Frenum 250 

Bednar's  Aphthae '    ....  250 

Catarrhal  Stomatitis 251 

Aphthous  Stomatitis  (Herpetic  Storhatitis) 252 

Thrush — -Sprue 253 

Ulcerative  Stomatitis 255 

Gangrenous  Stomatitis 257 

Pyorrhea  Alveolaris       . 260 

Uvulitis ...'....  260 

Diseases  of  the  Esophagus .  261 

Esophagitis 261 

Retro-esophageal  Abscess 262 

Diseases  of  the  Stomach  and  Intestines 263 

Vomiting 263  , 

In  Early  Infancy 263 

Symptomatic  Vomiting .  263 

Cyclic  Vomiting 264 

Gastralgia 266 

Indigestion 267 

Fat  Indigestion » 267 

Carbohydrate  Indigestion 269 

Protein  Indigestion 271 

Feces 273 

Acute  Gastric  Indigestion .      .  274 

Acute  Gastritis ^ 275 

Gastroduodenitis 279 

Acute  Gastro-enteritis — Summer  Diarrhea — Summer  Complaint  .  279 

Acute  Enterocolitis 287 

Dysentery 289 

Cholera  Infantum 292 

Chronic  Gastritis 295 

Dilatation  of  the  Stomach 299 

Pylorospasm 301 

Hypertrophic  Pyloric  Stenosis 305 

Pyloric  Stenosis  in  Older  Children 308 

Enteralgia,  or  Colic 312 

Hematemesis 314 

Gastric  Ulcer 314  . 

Chronic  Intestinal  Indigestion 316 

Chronic  Ileocolitis 320 

Intussusception 323 

Chronic  Constipation 326 

Incontinence  of  Feces 330 

Diarrhea 331 

Intestinal  Bacteria 332 

Mucous  Colitis 333 

Amyloid  Disease  of  the  Intestines 334 

Intestinal  Obstruction 334 

Volvulus 335 

Appendicitis 335 

Gangrenous  Appendicitis 338 

Chronic  Appendicitis 339 


CONTENTS  xui 

Diseases  of  the  Stomach  and  Intestines — 

Intestinal  Worms ^_^  ........  341 

Cestodes 341 

Taeniae,  or  Tapeworms 341 

Taenia  Sohum,  or  Pork  Tapeworm 342 

Taenia  Mediocanellata,  or  Beef  Tapeworm 342 

Bothriocephalus  Latus,  or  Fish  Tapeworm         ....  342 

Dwarf  Tapeworm — Taenia  Nana 342 

Nematodes 344 

Oxyuris  Vermicularis — Threadworm 344 

Ascarls  Lumbricoides — ^Roundworm 346 

Trichocephalus  Dispar 347 

Ankylostomum  Duodenale — Hookworm 348 

Trichina 350 

Diseases  of  the  Peritoneum 351 

Acute  Peritonitis 351 

Chronic  Peritonitis 354 

Ascites      . 356 

Inguinal  Hernia        .      .      .      .      .            .      . 358 

Diseases  of  the  Rectum  and  Anus 361 

Proctitis 361 

Prolapse  of  the  Rectum  (Procedentia  Recti) 362 

Rectal  Polypi 364 

Hemorrhoids 365 

Fissure  in  Ano .  365 

Spasm  of  the  Anus 366 

Anal  Fistula} >     ! 366 

Ischiorectal  Abscess       .      . 367 

Diseases  of  the  Liver • 368 

Size  and  Location  of  the  Liver 368 

BUe 369 

Jaundice  or  Icterus 369 

Obstructive  Jaundice 369 

Hematogenic  Jaundice .371 

Congestion  of  the  Liver 372 

Enlargement  of  the  Liver 373 

Congenital  Acholuric  Jaundice 373 

Congenital  Obliteration  of  the  Bile  Ducts 375 

Stenosis  of- the  Bile  Ducts 376 

Acute  Yellow  Atrophy  of  the  Liver 376 

Cholelithiasis 378 

Abscess  of  the  Liver 378 

Subphrenic  Abscess 379 

Functional  Disorders  of  the  Liver 380 

Cirrhosis  of  the  Liver 381 

Amyloid  Liver 384 

Fatty  Liver 385 

Tuberculosis  of  the  Liver 386 

Syphilis  of  the  Liver 387 

Tumors  of  the  Liver 388 

Cysts  of  the  Liver 389 

Diseases  of  the  Pancreas 389 

Acute  Pancreatitis '  .      .      .      .  389 

Chronic  Pancreatitis 390 

Tuberculosis  of  the  Pancreas 390 


xlv  CONTENTS 


CHAPTER  XIV. 

Diseases  of  the  Respiratory  Tract. 

Anomalies 391 

Diseases  of  the  Nasopharynx . 391 

Acute  Rhinitis 391 

Chronic  Rhinitis 394 

Atrophic  Rhinitis 395 

Purulent  Rhinitis 395 

Epistaxis 395 

Adenoids .  396 

Diseases  of  the  Larynx 400 

Acute  Laryngitis  (False  Croup — Spasmodic  Croup) 400 

Edema  of  the  Larynx  (Glottis)  and  the  Submucous  Membrane    .  402 

Serous  Infiltration 402 

Inflammatory  Edema ., 403 

Laryngismus  Stridulus  (Child-crowing) 404 

Congenital  Laryngeal  Stridor 405 

New  Growths  of  the  Larynx 406 

Foreign  Bodies  in  the  Larynx,  the  Trachea,  and  the  Bronchi        .      .  407 

Diseases  of  the  Bronchi .  408 

Acute  Bronchitis 408 

Diseases  of  the  Lungs 414 

Pneumonia '. 414 

Lobar  Pneumonia 414 

Bronchopneumonia 423 

Diseases  of  the  Pleura 430 

Pleurisy — Serous  and  Purulent 430 

Reflex  Cough 438 

Asthma 439 

Abscesses  of  the  Lung 442 

Gangrene  of  the  Lung 442 

Acquired  Atelectasis,  or  Pulmonary  Collapse 443 

Emphysema 444 

CHAPTER  XV. 

Diseases  of  the  Heart. 

The  Heart 445 

The  Pulse • 446 

The  Apex  Beat 446 

Murmurs 447 

1.  Pulmonary  Systolic  Murmurs 448 

2.  Cardiopulmonary  Murmurs 448 

3.  Intracardiac  Murmurs 449 

Congenital  Diseases  of  the  Heart 450 

I.  Abnormal  Persistence  of  Fetal  Conditions 452 

II.  Deformities  of  Valves 453 

III.  AbnormaUties  of  Vessels  and  of  the  Cavities  of  the  Heart     .            .  454 

Physical  Examination  in  Diseases  of  the  Heart 454 

Palpation 455 

Percussion 455 

Auscultation 456 


CONTENTS  XV 

The  General  Symptoms  of  Heart  Disease 456 

Acute  Endocarditis          457 

Chronic  Endocarditis,  or  Acquired  Valvular  Disease 461 

Acute  Pericarditis 465 

Adherent  Pericarditis 467 

Myocarditis 469 

CHAPTER  XVI. 
Diseases  of  the  Blood. 

The  Blood  in  Infancy  and  Childhood 472 

Physical  Properties 472 

Hemoglobin 472 

Red  Cells 472 

Leukocytes 473 

Blood  Platelets , 475 

Blood  Dust .      .      : 475 

Anemia 475 

Secondary,  or  Simple,  Anemia 475 

The  Primary  Anemias 476 

Chlorosis 476 

Pernicious  Anemia 478 

Leukemia 479 

Pseudoleukemia  of  Infants  (von  Jaksch) 481 

Splenic  Anemia  (Banti's  Disease) 483 

Lymphatic  Anemia  (Pseudoleukemia:  Hodgkin's  Disease) 484 

Hemorrhagic  Diseases 487 

Hemophilia  (Bleeder's  Disease) 487 

Purpura 489 

Purpura  Simplex 490 

Purpura  Hemorrhagica 491 

Purpura  Rheumatica 492 

Henoch's  Purpura 492 

CHAPTER  XVII. 

Diseases  of  the  Ductless  Glanbs. 

Splenitis 493 

Perisplenitis 494 

Abscess  of  the  Spleen 494 

Wandering  Spleen .  494 

Primary  Splenomegaly 495 

New  Growths  of  the  Spleen 495 

Diseases  of  the  Lymph  Glands 495 

Simple  Acute  Adenitis 495 

Simple  Chronic  Adenitis 497 

Tuberculous  Adenitis , 498 

Diseases  of  the  Thymus  Gland 499 

Atrophy  of  the  Thymus 504 

Enlargement  of  the  Thymus 504 

Status  Lymphaticus 507 


xvi  CONTENTS 

Diseases  of  the  Thyroid  Gland 508 

Goitre 508 

Exophthalmic  Goitre  (Graves's  Disease) 509 

Cretinism 510 

Diseases  of  the  Adrenal  Glands       .      .      .  • 514 

Addison's  Disease 514 

The  Pineal  Gland 516 

The  Pituitary  Gland 516 

CHAPTER  XVIII. 

Diseases  of  the  Bones  and  Joints. 

Acute  Infectious  Osteomyelitis        .      .      . 517 

Tuberculosis  of  Bones 518 

Syphilis  of  Bones 519 

Dactylitis 520 

Craniotabes 521 

Bossing  of  the  Skull 522 

Acute  Arthritis  of  Infants .  522 

Tuberculosis  of  Joints 523 

CHAPTER  XIX. 

Diseases  of  the  Genito-xjrinary  System. 

Diseases  of  the  Kidney 525 

The  Urine 525 

Hematuria ' 526 

Hemoglobinuria      . .      .      .      .      .  527 

Functional  Albuminuria  (Postural,  Cyclic,  and  Orlhotic  Albuminuria)  527 

Paroxysmal  Albuminuria 528 

Lithuria 528 

Acetonuria 529 

Indicanuria 530 

Glycosuria 530 

Fehling's  Test       .      .      .    ' .531 

Pyuria 531 

Dysuria 532 

Anuria 532 

Retention  of  Urine 533 

Polyuria .      .      ....      .  534 

Enuresis 534 

Nephritis • '    .      .  538 

Acute  Congestion  of  the  Kidneys      .      .            , 539 

Nephritis  in  Infancy .      .      .      .      .  539 

Acute  Diffuse  Nephritis 541 

Chronic  Nephritis . 547 

Chronic  Parenchymatous  Nephritis            548 

Perinephritis 551 

Tuberculosis  of  the  Kidney 553 

Renal  Calcuh 554 

Tumors  of  the  Kidneys 555 

Congenital  Cystic  Kidney .      . 557 

Hydronephrosis 561 

Movable  Kidney 562 


CONTENTS  xvii 

Diseases  of  the  Bladder 563 

Pyelitis 563 

Cystitis 567 

Vesical  Spasm 568 

Vesical  Calculi  (Urethral  Calculi) 569 

Urethritis 570 

Specific  Urethritis ' 570 

Diseases  of  the  Reproductive  Organs 571 

Phimosis : 571 

Paraphimosis 572 

Balanitis 572 

Torsion  of  the  Spermatic  Cord 572 

Acute  Orchitis 573 

Tuberculous  Orchitis 573 

Tumors  of  the  Testicle 574 

Vulvovaginitis 575 

Simple  Vulvovaginitis 575 

Gonorrheal  Vulvovaginitis 576 

Gangrene  of  the  Vulva 580 

Vicarious  Menstruation 581 

Menstruation  Precox 581 

Masturbation 582 

CHAPTER  XX. 

Diseases  of  the  Skin. 

Eczema 586 

Urticaria  (Nettle  Rash:  Hives) 588 

Ichthyosis 589 

Intertrigo 590 

Impetigo  Contagiosa 591 

Furunculosis 592 

Miharia 593 

Erythema  Multiforme 593 

Seborrhea 593 

Psoriasis 594 

Tinea 594 

Tinea  Tonsurans 595 

Tinea  Circinata 596 

Herpes 596 

Herpes  Zoster  (Shingles) 597 

Warts  (Verrucse) 597 

Alopecia 598 

Alopecia  Areata 598 

Nfievi 600 

Gangrenous  Dermatitis 601 

Pemphigus  Neonatorum 601 

Dermatitis  Exfoliativa  Neonatorum 602 

MoUuscum  Contagiosum 602 

Parasitic  Skin  Diseases 603 

Pediculosis 603 

Scabies 604 

Dermatitis  Medicamentosa 605 

Tuberculosis  Cutis ...  606 


xviii  CONTENTS 

CHAPTER  XXI. 

Diseases  of  the  Ear. 

Foreign  Bodies  in  the  Ear 607 

Acute  Otitis  Media 607 

Chronic  Suppurative  Otitis  Mediaj 612 

Acute  Mastoiditis 614 

CHAPTER  XXII. 

The  Specific  Infectious  Diseases. 

Typhoid  Fever 617 

Typhoid  Fever  in  the  Fetus 618 

Typhoid  Fever  in  the  Infant 619 

Typhoid  Fever  in  the  Older  Child 620 

Parathyphoid  Fever 627 

Scarlet  Fever  (Scarlatina) 628 

Varicella  (Chicken-pox) 639 

Measles  (Morbilli— Rubeola) 642 

Rubella  (Rotheln — German  Measles) .  653 

Diphtheria 656 

Nasal  Diphtheria 660 

Laryngeal  Diphtheria,  or  Membranous  Croup 665 

Pseudodiphtheria 686 

Pertussis  (Whooping-cough) 688 

Mumps  (Epidemic  Parotitis) 699 

Influenza  (La  Grippe:  Catarrhal  Fever) 701 

Smallpox  (Variola) 707 

Varioloid 710 

Abortive  Types 710 

Vaccinia  (Cow-pox) 713 

Vaccine  Virus 714 

Humanized  Virus 714 

Bovine  Virus 715 

Vaccination 715 

Tuberculosis 717 

Pulmonary  Forms 722 

Tuberculous  Bronchopneumonia 722 

Miliary  Tuberculosis 722 

Acute  Miliary  Tuberculosis 722 

CUnical  Varieties 723 

Chronic  Tuberculosis 725 

General  Tuberculosis 726 

Tuberculosis  of  the  Glands — Lymphatic  Glands,  Bronchial     ....  726 

Cervical  Glands , 727 

Mesenteric  Glands .      .      .      .      .  727 

Pleura 727 

Heart 727 

Brain 728 

Liver 728 

Spleen 728 

Intestines 728 

Peritoneum 728 

Kidney 728 

TubercuUn  Tests 729 


CONTENTS  XIX 

Malaria "^^^ 

The  Parasite 733 

Clinical  Forms  of  Malaria 734 

Pernicious  Malaria '3" 

Syphilis 738 

Acquired  Syphilis '^^ 

Hereditary  Syphilis '39 

Early  Syphilis 743 

Late  Hereditary  Syphilis "^  •  745 

CHAPTER  XXIII. 

Rheumatism. 

Acute  Articular  Rheumatism 747 

Muscular  Rheumatism 757 

Chronic  Rheumatism 758 

Still's  Disease 758 

Rheumatoid  Arthritis — ^ Arthritis  Deformans /     .      .  759 


CHAPTER  XXIV. 

Scurvy •  763 

CHAPTER  XXV. 

The  Nervous  System. 

I.  Introduction 769 

Morphology  ...'.... 769 

Histological  Structure 769 

Physiological  Development 770 

Psychological  Development '    .      .      .      .  771 

Pecuharities  of  the  Nervous  System  of  the  Child 771 

II.  Examination  of  the  Nervous  System 772 

Normal  Reflexes 773 

Abnormal  Reflexes 773 

Hypotonus 774 

Sensory  Examination 774 

Electrical  Examination       .      .      .    _ .      .      .  ' 774 

Reaction  of  Degeneration 774 

III.  Lumbar  Puncture 775 

Pressure  of  the  Spinal  Fluid 776 

Laboratory  Examination 776 

IV.  Cranial  and  Cerebral  Puncture 778 

Diseases  of  the  Spinal  Cord       . 778 

Malformations 778 

Rachischisis 779 

Myehtis 779 

Transverse  Myelitis 779 

Compression  Myelitis 781 

Caries — Spondyhtis  Tuberculosa — Pott's  Disease 781 

Landry's  Paralysis — Acute  Ascending  Paralysis 783 

Acute  Anterior  Poliomyelitis — Infantile  Paralysis 784 

Cerebral  and  Abortive  Types 791 


XX  CONTENTS 

Diseases  of  the  Spinal  Cord — Acute  Anterior  Poliomyelitis — 

Progressive  Muscular  Atrophy 795 

Early  Infantile  Spinal 795 

Adult  Form 7*96 

Amyotrophic  Lateral  Sclerosis 796 

Neural  Form  of  Progressive  Muscular  Atrophy,  Peroneal  Type       .  797 

Progressive  Muscular  Dystrophy 798 

Pseudohypertrophic  Type 798 

Juvenile  Type,  Scapulohumeral 801 

Infantile  Type,  Facies-scapulohumeral       .......  801 

Simple  Atrophic  Type,  Hereditary 801 

Myotonia  Congenita  (Thomsen's  Disease) 802 

Myotonia  Congenita  (Opphenheim) 803 

Syringomyelia 803 

Hereditary  Ataxia  (Friedreich's  Ataxia) — Hereditary  Cerebellar  Ataxia 

(Marie) 804 

Spinal  Form 805 

Tumors  of  the  Spinal  Cord 806 

Diseases  of  the  Meninges 808 

Pachymeningitis 808 

Pachymeningitis  Externa 808 

Pachymeningitis  Interna 808 

Purulent  Pachymeningitis  Interna .  808 

Pachymeningitis  Interna  Hemorrhagica 808 

Acute  Suppurative  Meningitis 810 

Pneumococcic  Meningitis 812 

Septic,  Streptococcic,  and  Staphylococcic  Meningitis       ....  812 

Influenzal  Meningitis 812 

Typhoid  Meningitis :      .  813 

Cerebrospinal  Meningitis — Epidemic  Meningitis 814 

Clinical  Forms  and  Course 816 

Tuberculous  Meningitis 819 

Atypical  Cases ' 822 

Diseases  of  the  Brain 824 

Cerebral  Palsies 824 

Infantile  Hemiplegia 825 

Cerebral  Diplegia — Spastic  Paraplegia — Little's  Disease        .      .      .  826 

Idiocy       . 828 

Amaurotic  Family  Idiocy 832 

Mongolian  Idiocy 833 

Diseases  of  the  Nerves    . 835 

Multiple  Neuritis 835 

Diphtheritic  Paralysis 836 

Postinfections  (Non-diphtheritic) .      .      .      .      .  838 

Toxic — Alcoholic,  Lead,  and  Arsenical 839 

Facial  Paralysis. 839 

Chorea 841 

Tetany 846 

CHAPTER  XXVI. 

Puberty. 

Period  Preceding  Puberty 851 

Body 852 

Mind 855 


DISEASES  OF  CHILDREN. 


CHAPTER  I. 
THE  NORMAL  INFANT  AT  BIRTH. 

General  Appearance. — The  physical  proportions  of  the  normal 
infant  at  birth  show  a  striking  contrast  to  those  resulting  after  develop- 
mental adjustment.  The  head  appears  large  in  proportion  to  the  size 
of  the  body;  likewise,  the  shoulders,  arms  and  upper  chest,  when 
compared  with  the  pelvis  and  legs. 

The  child's  body  is  well  rounded,  being  covered  with  a  goodly  layer 
of  superficial  fat.  The  head  may  be  covered  by  a  moderately  thick 
growth  of  hair,  although  this  is  by  no  means  always  the  case;  strong, 
vigorous  children  showing  not  infrequently  at  birth  a  very  small 
growth  of  hair.  The  head  is  often  misshapen,  as  a  result  of  pressure 
during  labor.    ■ 

The  face  of  the  infant  in  the  first  few  months  of  life  is  small  in 
proportion  to  the  cranium,  and  is  as  1  to  8;  at  the  age  of  five  years, 
as  1  to  4;  and  in  adult  life  as  1  to  2  or  2|.  The  rapid  growth  of  the 
inferior  maxillary  bone  has  much  to  do  with  the  increased  facial  size. 
The  chest  of  the  infant  is  barrel  shaped,  the  anteroposterior  and 
transverse  diameters  being  about  the  same. 

The  abdomen  is  very  prominent,  being  much  larger  proportionately 
than  later  in  life.  This  is  due  to  the  large  size  of  the  liver  in  infants 
and  the  small  size  of  the  pelvis. 

The  feet  of  the  infant  are  distinctly  arched,  but  this  is  not  always 
apparent  on  account  of.  the  large  amount  of  fat  often  present. 

The  nails  project  beyond  the  fingers,  their  borders  being  very  brittle. 

The  color  of  the  body  immediately  after  birth  is  that  of  venous 
blood,  as  a  result  of  stasis  during  the  period  of  intra-uterine  pressure. 
As  this  is  removed,  and  respiration  becomes  established,  the  oxygen- 
ation of  the  blood  soon  manifests  itself  by  a  hyperemic  redness, 
resulting  within  a  few  days  in  exfoliation  which  persists  for  about  a 
week. 

Skin. — At  birth  the  delicate  integument  of  the  infant  is  frequently 
covered  with  a  material,  the  vernix  caseosa,  a  secretion  of  its  own 
sebaceous  glands,  with  exfoliated  epithelium  and  lanugo.  The  latter 
is  the  term  applied  to  the  soft,  downy  hair  covering  the  body  of  the 
fetus,  and  persisting  for  a  long  time  after  birth.  The  sweat  glands  of 
the  normal  infant  are  comparatively  inactive  for  several  weeks  after 
2 


IS  THE   NORMAL  INFANT  AT  BIRTH 

birth,  while  the  functional  activity  of  the  sebaceous  glands  is  marked, 
often  resulting  in  seborrhea  of  the  scalp.  The  skin  on  the  scalp  is 
thicker  than  elsewhere  on  the  body  and  adherent  to  the  occipito- 
frontalis  beneath  it. 

Head. — ^At  birth  the  head  is  capable  of  being  easily  molded,  often 
resulting  in  elongation  due  to  birth  pressure,  and  frec^uently  giving  it 
a  grotesque  appearance.  This  plasticity,  on  the  other  hand,  also 
permits  of  rapid  adjustment  of  the  cephalic  contour,  so  that  extensive 
disproportions  often  disappear  soon  after  birth.  The  fontanelles,  or 
membranous  spaces  between  the  bones  of  the  skull,  are  the  results  of 
incomplete  ossification,  and  are  important  landmarks  in  pediatrics 
as  they  are  in  obstetrics. 

The  largest,  the  anterior  fontanelle,  is  situated  at  the  junction  of  the 
coronal,  sagittal,  and  frontal  sutures;  it  is  rhomboid  in  outline,  with 
the  apex  projecting  anteriorly. 

The  posterior  fontanelle,  triangular  in  shape,  hardly  exists  as  an 
opening  at  birth,  the  bones  usually  lying  quite  close  together.  The 
Wormian,  or  supernumerary  bones,  are  frequently  encountered  along 
the  sutures  and  at  the  fontanelles. 

The  base  of  the  skull  in  the  newborn  differs  from  that  in  the  adult, 
in  that  there  are  no  mastoid  processes;  on  the  other  hand,  the  base 
of  the  skull  is  well  ossified,  notwithstanding  that,  during  fetal  develop- 
ment, the  base  of  the  skull  is  poor  in  ossification  as  compared  to  the 
vault. 

Thorax. — At  birth  the  thorax  is  extremely  compressible,  the  average 
circumference  of  the  chest  being  thirteen  inches.  The  clavicle  is  the 
first  bone  to  ossify,  and  also  the  one  most  frequently  fractured  during 
parturition.  The  humerus  at  birth  is  almost  entirely  ossified,  although 
the  extremities  of  the  bdne  are  composed  chiefly  of  cartilage. 

The  knee-joint  is  supplied  with  numerous  bursse,  distributed  among 
the  tendinous  attachments  of  the  various  muscles. 

Circulatory  System. — At  birth,  the  average  weight  of  the  heart  is 
about  two-thirds  of  an  ounce.  The  thickness  of  the  right  ventricle 
is  very  nearly  the  same  as  that  of  the  left,  the  ratio  being  6  to  7.  The 
left  ventricle,  however,  grows  very  much  more  rapidly  than  the  right, 
so  that  at  the  end  of  the  second  year  the  ratio  is  2  to  1,  which  is 
nearly  that  of  the  rest  of  childhood. 

In  the  fetus  the  connection  between  the  pulmonary  artery  and  the 
aorta  is  called  the  ductus  arteriosus.  There  also  exists  an  opening, 
the  foramen  ovale,  between  the  am'icles,  and  there  is  likewise  a  valve 
which  guides  the  blood  from  the  inferior  vena  cava  through  the  foramen 
ovale.  This  valve  becomes  atrophied  after  the  normal  circulation  of 
the  child  has  become  established.  The  fetal  circulation  is  characterized 
by  the  fact  that  arterial  blood  flowing  from  the  placenta  enters  the 
fetus  by  means  of  the  umbilical  vein. 

Post-natal  Circulation. — The  transition  of  the  fetal  circulation  to 
that  after  birth  is  characterized  by  several  well-defined  features. 
As  respiration  becomes   established,  and  the  pulmonary  circulation 


GENERAL  APPEARANCE  19 

begins,  the  patulous  foramen  ovale  and  the  ductus  arteriosus  gradually 
close,  the  expansion  of  the  lungs  and  the  filling  of  their  bloodvessels 
inaugurating  the  independent  circulation  by  reason  of  the  effect  of 
the  increased  blood-pressure  in  the  aorta  upon  the  valve-like  ductus 
arteriosus.  Furthermore,  the  blood  which  is  emptied  into  the  left 
side  of  the  heart  exerts  a  mechanical  pressure  upon  the  valve  closing 
the  foramen  ovale. 

The  interruption  of  the  placental  circulation,  together  with  the 
ligation  of  the  umbilical  cord,  finally  causes  an  atrophy  of  the  ductus 
venosus  and  umbilical  veins,  converting  them  into  a  strand  of  fibrous 
tissue,  the  round  ligament  of  the  liver. 

Arteries. — The  relation  between  the  size  of  the  heart  and  the  diameter 
of  the  arteries  in  the  newborn  is  inverse  to  that  of  the  adult.  In  the 
latter  the  heart  is  quite  large  compared  to  the  diameter  of  the  arteries, 
while  in  children  the  heart  is  small  and  the  caliber  of  the  arteries  is 
large.  It  is  manifest,  therefore,  that  the  blood-pressure  in  children  is 
relatively  low;  on  the  other  hand,  it  is  quite  high  in  the  pulmonary 
circulation,  on  account  of  the  larger  caliber  of  the  pulmonary  artery 
as  compared  to  that  of  the  ascending  aorta. 

Blood.' — After  birth,  and  before  ligation  of  the  umbilical  cord,  a 
certain  amount  of  blood  enters  the  child,  resulting  in  plethora.  Soon 
after  birth,  however,  an  equilibrium  is  established,  due  to  excretion 
of  fluids  and  a  concentration  of  the  blood.  There  is  consequently  a 
high  color  index,  which  soon  disappears.  The  red  blood  corpuscles 
are  present  in  all  sizes,  nucleated  ones  being  frequently  present  for 
several  days  after  birth.  The  blood  of  the  newborn  contains  more 
leukocytes  than  that  of  the  adult.  The  number  of  erythrocytes  in  the 
newborn  and  in  very  young  children  varies  from  4,340,000  to  6,500,000. 

Pulse. — The  activity  of  the  circulation  is  very  much  more  pronounced 
at  birth  and  early  infancy  than  in  later  life.  It  is  estimated  that  the 
entire  circulatory  cycle  in  the  infant  is  completed  in  twelve  seconds. 
The  pulse  is  slightly  more  frequent  in  females  than  in  males.  At 
birth,  and  even  during  infancy,  a  very  rapid  and  irregular  pulse  may 
be  compatible  with  good  health;  it  may  be  noted  even  during  sleep. 

Digestive  System. — The  organs  of  the  digestive  system  in  the  new- 
born and  in  infancy  possess  peculiarities  which  markedly  differentiate 
them  from  those  of  the  adult.  This  is  true  not  only  of  diseases  of  these 
structures,  but  is  inherent  in  their  anatomy  and  physiology.  Among 
the  most  pronounced  peculiarities  of  the  mouth  are  the  dryness  and 
thinness  of  the  oral  mucous  membrane,  the  deficiency  of  the  sali\'ary 
secretion  at  birth  as  well  as  its  weakness  in  enzymosis.  The  absence 
of  prehension  is  compensated  by  the  suction  produced  by  the  lingual 
musculature  and  pressure  of  the  cheeks.  The  stomach  is  small,  almost 
vertical,  and  the  fundus  is  practically  undeveloped. 

The  gastric  juice  contains  essentially  the  constituents  of  that  of  the 
adult,  while  the  pancreatic  juice,  on  the  other  hand,  is  incomplete 
in  its  action  on  fats.  The  intestines  are  relatively  longer  than  in  the 
adult  and  poor  in  the  development  of  Lieberkiihn's  and  Brunner 's  glands. 


20  THE  NORMAL  INFANT  AT  BIRTH 

The  liver  in  the  newborn  is  large  and  vascular,  the  volume  being 
greater  than  that  of  the  two  lungs  combined,  the  ratio  not  being 
reversed  until  the  advent  of  puberty.  The  bile  is  poor  in  inorganic 
salts,  excepting  iron. 

Respiratory  System. — The  caliber  of  the  nasal  passage  in  the  newborn 
is  very  small.  The  larynx  is,  likewise,  very  narrow,  which  is  important 
to  appreciate  in  considering  intubation  in  an  infant.  The  trachea  at 
birth  is  flattened  anteriorly  and  posteriorly,  and  remains  so  for  some 
time,  notwithstanding  the  distention  from  respiration.  The  surfaces 
of  the  cartilaginous  rings  are  in  apposition  until  the  trachea  becomes 
further  developed. 

Lungs. — At  birth  the  color  of  the  lungs  is  a  pinkish  gray;  the  direct 
chemical  action  of  the  blood  and  the  repeated  inspiration  of  air  soon 
changes  that  color  to  one  of  mottled  gray  and  black.  While  before 
birth  at  full  term  the  position  of  the  lungs  is  toward  the  posterior 
portion  of  the  thorax,  the  expansion  induced  by  birth  soon  causes 
them  to  cover  the  pleural  portion  of  the  pericardium  and  occupy  their 
permanent  position  in  the  thoracic  cavity.  The  weight  of  the  lungs 
before  birth  is  48  grams,  while  after  the  complete  establishment  of 
respiration  their  weight  is  increased  to  80  grams. 

Ductless  Glands. — The  thymus  gland  in  the  newborn  is  situated  in 
the  anterior  mediastinum  behind  the  manubrium  of  the  sternum,  and 
reaches  full  development  about  the  end  of  the  second  year.  It  is 
generally  composed  of  two  lobes  which  are  in  apposition  in  the  middle 
line.  After  the  second  j^ear  it  loses  its  identity  by  fat  substitution,  or 
entirely  disappears. 

The  thyroid  gland  in  the  newborn  is  relatively  very  large,  the  two 
lobes  being  united  transversely  by  an  isthmus.  The  parathyroids 
are  present  behind  the  lateral  lobes  of  the  thvToid  gland. 

The  bronchial  glands,  lymphatic  in  character,  consist  of  several 
groups ;  one  in  close  relation  with  the  trachea,  another  at  the  bifurca- 
tion of  that  structure;  others  at  the  roots  of  the  lungs,  known  as 
the  hilus  glands,  while  still  another  group  is  in  intimate  relation  with 
larger  bronchioles  as  they  enter  the  lungs. 

Genito-urinary  System. — The  kidneys  of  the  newborn  are  relatively 
large  and  do  not  increase  in  size  as  much  as  the  lungs  or  heart.  At 
birth  the  kidneys  are  practically  at  the  acme  of  their  functional  capacity, 
and  the  suprarenals  are  relatively  larger  than  in  the  adult  and  are 
extremely  vascular. 

The  bladder  in  the  newborn  is  oviform  in  shape,  the  smaller  end 
being  directed  upward,  the  bladder  descending  as  the  pelvis  develops. 
At  birth  the  bladder  is  capable  of  holding  from  2  to  4  drams. 

Both  the  ovaries  and  testicles  are  at  first  abdominal  organs,  and  only 
in  the  course  of  the  development  of  the  child,  begin  to  occupy  their 
respective  positions. 

The  uterus  at  birth  is  about  one  inch  in  length,  and  possesses  no 
fundus.  The  cervix,  on  the  other  hand,  is  thicker  and  longer  than  the 
remaining  portion. 


CARE  OF   THE  NEWBORN  21 

Nervous  System. — In  the  new})()r]i  the  nervous  system  is  in  a  xcry 
rudimentary  eoiKhtion.  The  brain  is  hiru'e,  watery,  and  vvvy  soft, 
and  shows  but  little  differentiation  of  gray  and  white  matter.  Likewise, 
the  spinal  cord  is  of  soft  consistency,  the  anterior  horns  being  more 
fully  developed  than  the  other  structures. 

Organs  of  Special  Sense. — ^At  birth,  and  for  some  time  thereafter,  the 
sclerotic  coat  of  the  eye  has  a  bluish  color,  due  to  the  underlying 
choroid  being  seen  through  the  slightly  transparent  sclera.  There  is 
no  coordination  in  the  excursions  of  the  extraocular  muscles.  The 
refraction  of  the  eye  at  birth  is  usually  hyperopic.  The  power  of 
fixation  is  also  absent.  While  the  power  of  convergence  may  be  present, 
it  will  not  produce  contraction  of  the  pupil  for  some  little  time  after 
birth.  The  color  of  the  iris  is  usually  blue  or  bluish  gray.  Photophobia 
in  the  presence  of  strong  light  is  a  constant  characteristic  of  the  newly 
born. 

The  ear  and  acuity  of  hearing  in  a  newborn  babe  are  very  poorly 
developed,  due  to  the  shortness  of  the  external  meatus  and  the  absence 
of  bony  formation.  It  is  surprising,  however,  how  soon  the  acuity  of 
hearing  in  childhood  reaches  its  acme. 

Taste. — This  sense  is  very  acute  at  birth,  the  newborn  having  been 
observed  on  frequent  occasions  to  signify  its  appreciation  or  dislike 
for  sweet  or  sour  substances  respectively.  The  slightest  alteration 
in  accustomed  food  is  quickly  detected  in  infancy,  a  bottle  often 
being  refused  when  there  has  been  the  smallest  possible  variation  in 
an  accustomed  food  mixture. 

Tactile  Sensation. — This  is  developed  at  birth,  more  especially  at 
the  lips  and  tongue,  where  its  utility  is  manifest  for  the  purpose  of 
nursing. 

Mammary  Glands. — At  birth  the  mammary  glands  are  normally 
congested  and  somewhat  swollen,  and  in  many  instances  secrete  a 
milk-white  jfluid.  They  are  from  one-third  to  one-fifth  of  an  inch  in 
diameter. 

Temperature. — The  temperature  of  the  newborn  and  of  the  young 
infant  is  exceedingly  unstable.  At  birth  the  rectal  temperature  is 
from  98.4°  to  100°  F.,  fluctuating  between  these  points  for  several 
weeks.  The  variation  in  the  temperature  is  easily  understood  when 
one  considers  the  large  siu-face  for  radiation  and  the  facility  with  which 
heat  is  disseminated  from  the  easily  dilated  capillaries  in  the  infant. 
A  great  many  observations  have  shown  that  the  temperature  of  infants 
begins  to  rise  in  the  forenoon,  reaches  its  fastigium  in  the  course  of  the 
afternoon,  and  then  declines.  The  temperature  is  at  its  minimum 
during  the  night  and  early  morning  hours,  and  at  its  maximum  in  the 
early  afternoon. 

CARE  OF  THE  NEWBORN. 

Bathing.^ — As  soon  as  possible  after  birth  the  child  should  be  bathed. 
In  order  that  no  delay  may  occur  during  the  bath,  all  preparations 
should  be  made  beforehand.    The  time  of  giving  the  bath  should  be 


22  THE  NORMAL  INFANT  AT  BIRTH 

fixed  at  a  cei'laiii  hour  eadi  momiug,  neitJici'  just  l)et'()rc  nor  after 
feeding,  nor  immediatel\'  preceding  tlie  taking  of  the  child  out  of 
doors.  The  temperature  of  the  room  should  be  72°  F.  In  winter,  if 
possible,  the  child  should  be  bathed  before  an  open  fire,  care  being 
taken  not  to  place  the  infant  in  any  line  of  draught. 

The  best  basin  is  the  one  divided  in  two  portions,  and  supported 
at  a  convenient  height  by  an  iron  frame.  A  small,  fine  sponge  should 
be  used  to  cleanse  the  face,  corners  of  the  eyes  and  ears;  a  small  piece 
of  soft  linen  or  muslin  to  cleanse  the  nose.  The  head  is  now  washed 
with  pure  castile  soap,  the  soap  cleansed  off"  carefully  and  the  head 
dried,  the  child's  head,  during  this  portion  of  the  bath,  being  allowed 
to  fall  back  on  the  hand  of  the  nurse,  care  being  taken  to  prevent  soap 
getting  in  the  eyes.  The  water  in  the  other  portion  of  the  basin  is  now 
used  on  the  body,  with  castile  soap,  special  care  being  given  the  axillae, 
groins,  genitals,  and  anal  region. 

The  child  is  now  quietly  lowered  into  its  tub — for  infants  the  one  of 
rubber,  for  older  children  the  ordinary  tin  tub — and  allowed  to  kick 
and  move  its  body  freely  for  two  or  three  minutes.  The  baby  is  then 
rubbed  and  dried  quickly  with  warm  towels;  its  clothing  being  all 
previously  arranged,  it  is  quickly  dressed  and  returned  to  its  crib. 
This  bath  should  be  given  every  day,  care  being  taken  that  the  rubber 
tub  does  not  become  overheated,  as  severe  burns  may  result  from  the 
baby  being  placed  in  the  tub  if  the  rubber  has  become  too  hot  by  being 
stationed  near  an  open  fire. 

The  temperature  of  the  bath  is  important,  as  a  child's  circulation 
is  easily  depressed,  and  coldness  and  blueness  of  the  extremities  easily 
produced.  The  temperature  of  the  bath  at  different  ages  is  shown  in 
the  following  table : 

At  birth,  98°  F. 

At  two  weeks,  96°  F. 

At  one  month,  94°  F. 

At  one  month  to  six  months,  92°  F. 

Six  months  to  one  year,  90°  F. 

One  year  to  two  and  one-half  years,  86°  F. 
The  ordinary  bath  thermometer  is  easy  to  read  even  by  an  untrained 
nurse.     It  is  protected  by  a  wooden  cover  and  does  not  sink;  it  is 
indispensable  in  a  well  conducted  nursery. 

Clothing. — The  clothing  of  all  infants  and  children  should  be  loose, 
especially  around  the  neck,  chest,  abdomen,  and  pelvis.  In  order  that 
the  chest  may  develop  properly  and  the  normal  action  of  the  lungs  be 
not  restricted,  it  is  absolutely  essential  that  no  compression  whatever 
of  the  thorax  be  permitted.  The  proper  performance  of  digestion, 
the  motor  activity  of  the  stomach  and  intestines,  and  the  normal 
circulation  and  functions  of  all  the  abdominal  organs  may  be  more 
or  less  interfered  with  unless  quite  loose  garments  are  worn.  The 
wearing  of  diapers  tightly  drawn  and  pinned  is  an  undoubted  factor 
in  the  development  of  pelvic  deformities. 

All  clothing  should  be  supported  from  the  shoulders  and  not  from  the 


CARE  OF   THE  NEWBORN  23 

chest  or  hips,  ('arc  must  always  he  taken  to  keep  the  cxtrcDiities 
warm,  especially  the  hands  and  feet. 

The  abdominal  band  can  be  dispensed  with  after  the  second  month. 
The  knitted  binder  fitting  the  body  snugly  and  provided  with  arm- 
holes  is  the  best  form  to  use. 

In  summer,  gauze  or  very  light  flannel  underwear  is  the  best.  A 
child  must,  however,  be  dressed  wdth  a  view  to  its  circulation;  a  thin 
delicate  baby,  with  poor  circulation,  requires  more  clothing  than  one 
whose  body  is  well  co\'ered  with  a  plentiful  supply  of  fat. 

At  night,  infants  should  wear  a  shirt  of  cotton  or  wool,  a  napkin, 
cotton  stockings,  and  a  long  outer  garment  of  light  flannel,  made  with 
a  drawing  string  or  buttons  at  the  bottom,  and  sufficiently  wide 
not  to  confine  the  legs.  This  insures  the  lower  extremities  being 
covered  during  the  night. 

The  infant  or  long  clothes  consist  of  a  binder  worn  during  the  first 
two  months;  shirt  with  sleeves,  napkin,  long  stockings,  flannel  petti- 
coat, w^hite  petticoat,  a  long  dress,  and  light  flexible  shoes  or  knitted 
socks.  Diapers  should  not  be  too  heavy  or  cumbersome;  one  of  the 
best  materials  is  birdseye. 

All  shoes  should  be  large,  broad-toed,  and  made  rights  and  lefts. 
If  not  so  made  the  child's  feet  are  turned  from  their  normal  line,  the 
axis  of  the  great  toe  changed,  and  the  normal  movement  and  growth 
of  the  feet  impeded.  A  light  and  graceful  step  depends  largely  upon 
the  strength  and  elasticity  of  the  toes.  The  soles  of  children's  shoes 
should  be  flexible,  for  if  stiff  the  active  movements  of  the  muscles  of 
the  feet  are  interfered  with.  These  muscles  are  especially  active  in 
children. 

All  clothing  must  be  worn  with  due  regard  to  climate  and  sudden 
changes  in  the  weather.  The  tendency,  undoubtedly,  is  to  bundle 
children  up  too  much.  It  is  not  advisable  to  change  the  weight  of  the 
underclothing  too  frequently.  A  heavier  or  lighter  coat  is  a  much 
better  arrangement  for  changes  in  the  temperature.  In  winter,  the 
head,  and,  in  quite  cold  weather,  the  ears,  should  be  covered  with  a 
woolen  cap.  In  summer,  the  ordinary  hat  of  light  straw  with  broad 
brim  is  the  best. 

Sleep. — The  bedroom  should  be  large,  airy,  and  sunny.  The  curtains 
should  be  of  muslin  or  linen  to  insure  easy  and  frequent  washing.  The 
light  may  be  excluded  by  dark  shades.  All  superfluous  and  heavy 
draperies  should  be  dispensed  with,  and  the  floor  covered  with  light, 
inexpensive  rugs  or  carpet. 

The  temperature  of  the  infant's  room  should  not  fall  below  60°  F. 
during  the  night.  The  day  nursery  and  sleeping  apartment  should 
always,  if  possible,  be  separate  rooms.  Each  child  should  have  a 
separate  bed,  and,  if  practicable,  older  children  should  room  alone. 

During  the  first  two  months  of  life  the  child  requires  about  twenty 
hours  of  sleep  out  of  each  twenty-four.  As  it  grows  older  the  amount  of 
sleep  required  gradually  becomes  less.  From  the  age  of  two  months 
to  six  months,  sixteen  hours;  at  one  year,  fifteen  hours;  and  at  eighteen 


24  THE  NORMAL  INFANT  AT  BIRTH 

months,  thirteen  to  fourteen  hours.  A  child  two  and  a  half  years  old 
should  sleep  twelve  hours,  a  portion  of  this  being  a  nap  during  the  day, 
and  if  j^ossible  this  sleep  dm-ing  the  day  should  be  kept  up  until  the 
child  is  five  or  six  years  old,  and  should  be  taken  in  the  open  air.  At 
night  the  windows  of  the  sleeping  room  should  be  kept  wide  open. 

Infants  should  be  put  to  bed  between  six  and  seven  o'clock;  older 
children,  between  seven  and  eight  o'clock.  Regularity  of  sleeping 
should  be  instituted  at  birth,  and  much  depends  upon  training.  Healthy 
children,  if  kept  in  their  own  crib,  in  a  quiet,  dark  room,  not  handled  - 
unnecessarily,  and  only  disturbed  to  be  fed,  bathed,  clothed,  and  to 
have  soiled  linen  changed,  will  rarely  fail  to  obtain  the  prescribed 
number  of  hours  of  sleep. 

Slight  causes  may,  however,  keep  the  child  awake.  An  overheated 
or  poorly  ventilated  room  and  too  much  bedclothing  are  among  those 
causes  most  frequently  overlooked.  If  there  is  decided  restlessness 
in  sleep,  or  a  marked  reduction  in  the  amount  of  sleep,  it  usually 
indicates  illness  of  some  kind  and  should  be  carefully  investigated. 

The  crib  should  be  provided  with  high  sides  or  an  inexpensive 
wooden  fence,  otherwise  the  child,  after  the  tenth  month,  may  be 
severely  injured  by  falling  out  of  its  bed.  A  good  set  of  springs,  a 
moderately  firm  mattress,  preferably  of  hair,  and  a  small,  flat  hair 
pillow  not  over  three  inches  thick  is  the  best  suited  for  the  baby. 
The  mattress,  to  be  kept  clean  and  sweet,  must  be  protected  by  a 
rubber  sheet. 

Exercise. — The  infant  if  put  in  its  crib  without  bed  covering  and  its 
clothing  loose  will  kick  and  move  the  arms  vigorously,  giving  evidences 
of  its  pleasure  by  sounds  as  expressive  as  words.  Occasionally,  by 
placing  the  child  on  its  abdomen  the  spine  will  be  seen  to  bend 
vigorously  and  the  head  be  bent  backward,  while  the  arms  are  often 
used  to  advantage.  At  the  age  of  eight  to  nine  months  the  infant 
usually  begins  to  creep,  a  process  that  calls  into  action  almost  all  the 
muscles  of  the  body. 

When  one  year  to  fifteen  months  of  age,  infants  usually  stand  alone 
and  begin  to  walk.  It  is  not  wise  to  encourage  the  child  to  stand 
alone,  or  to  assist  it  much  in  walking,  unless  one  is  sure  that  its  failure 
to  walk  is  due  to  its  timidity,  and  not  to  lack  of  strength.  Manj' 
delicate,  rachitic  children  are  left  with  more  or  less  permanent  bowing 
of  the  legs  as  the  result  of  an  overproud  parent  teaching  his  child 
to  walk  too  soon. 

The  habit  of  propping  up  in  their  coaches  infants  of  twelve  months 
or  less  is  most  unwise.  The  spinal  column,  being  largely  composed  of 
cartilage  at  this  age,  -is  utterly  unfitted  to  support  the  superimposed 
weight.  As  a  result  of  this  increased  fiexibilit}^  of  the  spine  the  child 
leans  to  one  side,  the  spine  becomes  bent,  and  this  unnatural  position 
may  be  kept  up  for  hours,  the  child  even  possibly  falling  asleep,  and 
thus  the  foundation  is  often  laid  for  a  future  spinal  curvature.  For 
the  same  reason,  infants  when  carried  should,  if  possible,  be  kept  in  a 
horizontal  or  semiprone  position;  or  if  held  more  or  less  erect  the  back 


CAEE   OF    THE  NEWBORN  25 

should  be  well  supported  or  the  body  allowed  to  fall  forward  agaiust 
the  chest  and  shoulders  of  the  person  holding  it. 

The  time  when  a  l)aby  should  be  taken  outdoors  depends  largely 
upon  the  time  of  the  year  when  it  was  born  and  the  climate.  A.  child 
born  in  the  winter  or  fall  in  a  climate  such  as  Philadelphia,  where  the 
winters  are  moderately  severe,  should  not  be  taken  out  before  the  age 
of  two  months.  Then  on  mild,  sunshiny  days  with  little  wind  the  baby 
may  be  taken  out  for  a  half  to  one  hour,  well  bundled  up  in  its  coach, 
and  its  face  protected  by  a  veil. 

When  two  months  old,  children  may,  for  the  same  length  of  time, 
be  wheeled  in  a  coach  in  the  nursery,  dressed  as  if  for  outdoors, 
the  windows  being  raised  and  all  doors  closed  to  avoid  draughts. 
This  makes  the  change  from  the  nursery  to  the  outside  air  less 
abrupt. 

Children  born  in  warm  weather  may  be  taken  out  when  three  weeks 
old.  The  eyes  of  all  infants  should  be  well  protected  by  a  parasol 
from  the  direct  rays  of  the  sun.  It  is  safer  to  keep  the  baby  indoors 
in  damp  w^eather,  or  on  days  when  the  thermometer  falls  below  20°  F., 
especially  if  there  is  a  strong  wind.  Older  children  usually  get  sufficient 
exercise  in  their  play,  which  is  to  be  preferred  to  long  walks,  the  latter 
being  often  fatiguing.  When  possible,  gardening  is  a  most  useful 
mode  of  exercise,  each  child  having  its  own  little  plot  for  plants  and 
flowers. 

A  roof  garden  may  be  made  to  suit  the  purse  of  the  poor  or  rich. 
If  used  in  summer  it  is  a  great  boon  to  those  unable  to  keep  their 
children  for  a  long  period  out  of  the  warm,  close  air  of  the  city.  It  is 
also  of  great  practical  use  in  winter. 

Fresh  Air. — The  infant  and  young  child  should  be  given  an  abundance 
of  fresh  outside  air,  and  if  the  child's  normal  bodily  temperature  is 
preserved,  and  the  hands,  feet,  and  ears  kept  warm,  no  injury  from 
fresh  outside  air  need  be  feared.  It  is  always  advisable,  when 
possible,  to  protect  the  child  from  draughts,  but  a  free  circulation 
of  air  through  the  nursery  and  bedroom  is  always  desirable.  An  open 
fireplace  is  of  great  advantage,  insuring  a  withdrawal  of  air  from  the 
room.  The  window  ventilator,  consisting  of  a  board  fitting  in  the 
window  with  the  pipes  directed  upward  to  admit  fresh  air,  answers 
admirably.  All  rooms  occupied  by  children  should  be  thoroughly 
flushed  out  once  a  day,  during  the  child's  absence. 

A  temperature  of  66°  to  70°  F.  is  suitable  for  the  nursery,  the 
former  being  better  than  the  latter.  The  child  when  six  weeks  old, 
warmly  clad,  may  be  taken  into  a  room  at  70°  F.,  and,  being  carefully 
kept  out  of  draughts,  a  window  may  be  raised  and  the  temperature 
allowed  to  fall  to  60°  F.  This  may  be  done  for  one  hour,  morning 
and  afternoon.  The  temperature  at  two  months  may  be  reduced 
tQ  50°  F.,  and  at  the  age  of  three  months  to  40°  F.  When  the  child 
is  taken  out  of  doors  in  cold  weather  a  veil  should  always  be  worn, 
the  hood  of  the  baby  carriage  should  always  be  kept  raised,  and  the 
coach  always  turned  so  as  to  protect  the  infant  from  cold  winds.     Xo 


26  THE  NORMAL  INFANT  AT  BIRTH      , 

luii'in  ))iil  great  hcnefil  ivsults  from  those  daily  airings,  and  the  old 
l^rejudiee  about  taking  eold  should  not  be  eonsidered. 

Hot  water  heating  is  eleanly,  does  not  dr.y  the  air^  and  is  to  be 
preferred.  If  a  hot-air  furnace  is  used  the  radiators  should  be  covered 
with  cheesecloth. 

Eyes. — The  eyes  at  birth,  in  the  normal  infant,  are  fully  developed. 
As  soon  as  possible  after  birth  they  should  be  well  washed  with 
a  saturated  solution  of  boric  acid,  and  if  any  suspicious  vaginal  dis- 
charge is  present  in  the  mother  a  few  drops  of  a  solution  of  nitrate  of 
silver,  2  grains  to  the  ounce,  should  be  carefully  dropped  into  each 
eye  and  the  eyes  then  washed  with  normal  salt  solution.  The  eye-wash 
of  boric  acid  should  always  be  used  twice  daily  during  the  first  week 
of  life,  as  mild  forms  of  conjunctivitis,  non-gonorrheal  in  character, 
but  caused  by  the  entrance  into  the  eyes  of  discharges  from  the  vagina 
or  rectum  of  the  mother,  are  not  uncommon. 

The  mouth  should  be  very  gently  cleansed  with  a  piece  of  gauze 
dipped  in  a  saturated  boric  acid  solution,  care  being  taken  not  to  injure 
the  delicate  buccal  mucous  membrane.  During  the  first  two  weeks 
of  life  the  mouth  should  be  cleansed  just  before  each  nursing.  This  is 
of  advantage  to  both  niother  and  babe,  as  during  this  period  the 
nipples  of  the  mother  and  mouth  of  the  child  are  especially  liable  to 
become  the  seat  of  disease. 

Rash. — The  skin  of  the  newborn  babe  is  easily  irritated,  and  causes 
quite  incapable  of  doing  any  harm  in  older  children  may  produce 
erythema,  eczema,  or  intertrigo  in  infants,  especially  in  the  folds  of 
the  groins  and  genital  region.  Perfect  cleanliness,  the  use  of  castile 
instead  of  irritating  soaps,  keeping  the  folds  dry,  and  using  a  dusting 
powder  of  starch,  Ij'copodium,  or  zinc  oxide,  will  usually  be  found  all 
that  is  necessar}^  to  prevent  the  development  of  these  annoying 
conditions. 

Genitals. — The  genitals  should  be  kept  clean,  but  not  washed  oftener 
than  the  rest  of  the  body,  unless  soiled  by  vaginal  or  rectal  discharges. 
In  boys  the  prepuce  should  be  examined  and  retracted  daily,  if  tight 
or  long,  until  the  parts  are  in  a  normal  condition.  Circumcision  is 
often  necessary.  It  usually  removes  more  or  less  local  irritation.  It 
may  do  much  good — if  properly  performed  it  can  never  do  harm. 

It  is  important  that  the  child  should  be  taught  to  exercise  control 
of  the  bladder  and  rectum  quite  early  in  life.  When  six  months 
old  the  child  should  be  placed  in  its  chair  for  about  three  minutes  or 
less,  preferably  just  after  each  feeding.  If  this  rule  is  adhered  to 
systematically  the  majority  of  children  will,  at  the  age  of  one  year, 
have  learned  to  control  the  discharge  of  both  urine  and  feces.  This 
is  of  advantage  to  the  child,  as  the  evacuation  of  the  bladder  and 
bowel  at  certain  regular  intervals  is  important,  and  the  training  of 
the  child  itself  is  also  of  benefit. 

Anal  Region. — During  the  first  year  of  life  and  often  until  the  end 
of  the  second  year,  if  the  child  has  not  been  so  trained,  the  nurse  is 
compelled  each  day  to  devote  considerable  time  to  the  washing  of  the 


I  tvrrf 


CARE  OF   THE  NEWBORN  27 

iuii)kiiis,  Hiid  such  time  is  ])crli;i])s  tukeii  From  tJic  hours  whicli  the  child 
should  spend  iu  the  o})eu  air.  The  lun-se,  if  relie\'ed  of  this  washing, 
is  also,  in  my  exj^erience,  much  more  cheerful  and  manageable.  x\gain, 
it  is  certainly  not  hygienic  for  a  child  to  be  wearing  articles  of  clothing 
soiled  b.y  urinary  or  fecal  discharges  any  longer  than  is  necessary. 

Vaccination. — All  children  should  be  vaccinated  during  the  first 
year  of  life;  after  the  third  month  is  preferable;  and  better,  if  possible, 
during  the  cool  than  the  hot  months.  If  the  arm  is  properly  protected 
from  infection  by  an  appropriate  dressing  the  symptoms  produced  by 
vaccination  are  slight  and  temporary.  Vaccination  should  be  deferred 
in  a  child  who  is  frail,  ill,  or  suffering  from  anv  skin  disease. 


CHATTER  II. 
NORMAL  DEVELOPMENT  OF  THE  CHILD. 

As  a  rule,  it  may  be  stated  that  for  a  child  to  develop  according  to 
normal  standards,  certain  conditions  such  as  heredity,  environment, 
birth,  food,  and  hygienic  surroundings,  should  be  up  to  the  normal  or 
usual  standards.  Ideal  conditions  are  unnecessary,  but  the  better  the 
conditions  are  the  greater  is  the  probability  that  the  infant  will  develop 
properly. 

Normal  development  differs  greatly  in  races  and  in  the  same  race 
under  different  environment.  In  the  monkey  tribe  it  requires  from 
six  to  ten  years  to  reach  full  intellectual  and  physical  development. 
In  certain  African  races  the  span  of  life  is  only  thirty  years,  and  the 
children  of  these  savages  are  very  precocious.  They  walk  very  early, 
and  reach  puberty  and  full  intellectual  development  at  the  age  of  ten 
years. 

Caucasian  infants  of  civilized  countries  are  the  least  precocious 
of  all  races,  requiring  twenty-five  years  to  attain  full  mental  develop- 
ment; and,  as  the  developmental  period  is  the  most  important  one  in 
the  life  of  the  individual,  it  follows  naturally  that  we  cannot  be  too 
careful  that  the  individual  lives  during  this  period  under  conditions 
which  will  best  promote  his  mental  and  physical  progress. 

There  are  certain  portions  of  the  body  that  develop  rapidly  in  size, 
but  acquire  their  complete  functional  activity  slowly.  A  striking 
example  of  this  is  seen  in  the  infant  twelve  months  old,  whose  brain 
is  almost  two-thirds  as  large  as  the  adult's,  but  the  functions  of  this 
brain  require  years  of  careful  training  for  their  development.  It  is 
well  for  us  to  appreciate  that  normal  children  come  from  normal 
parents,  and  that  much  can  be  accomplished  by  a  better  physical, 
mental,  and  moral  training  of  the  masses.  If  the  physical  nature  alone 
is  developed  we  produce  a  race  of  athletes.  If  the  mentality  only  is 
cultivated  we  develop  a  people  among  whom  prodigies  and  precocious 
youths  are  the  rule  rather  than  the  exception.  If  only  the  moral  side 
is  developed  the  race  becomes  narrow-minded  and  fanatic. 

How  many  children  are  systematically  weighed  and  measured  to 
see  if  they  are  growing  and  developing  normally?  and  how  much  time 
do  parents,  as  a  rule,  give  to  the  study  of  their  child's  growth  and 
development?  Normal  development  is  more  likely  to  be  found  where 
systematic  medical  examinations  of  the  child  are  made.  This  is  now 
becoming  the  rule  among  the  better  educated,  and  school  physicians 
are  of  much  assistance  in  detecting  both  acute  and  chronic  conditions 
among  those  who  are,  perhaps,  less  often  taken  to  a  physician.  All 
children  who   are   compelled  to   work  should   be  pronounced   by  a 


NORMAL  DEVELOPMENT  OF   THE  CHILD  29 

physician  to  be  fit  and  capable  of  working  before  being  employed, 
and  the  law  concerning  age  limit  and  hours  of  employment  should  be 
strictly  enforced. 

During  school  life  many  factors  combine  to  retard  the  normal 
growth  of  children,  both  boys  and  girls.  The  daily  sessions  are  too 
long,  and  the  concentration  of  attention  demanded  by  lengthy  recita- 
tions is  also  too  great  a  tax.  Recesses  do  not  come  frequently  enough 
to  relieve  the  inactivity  and  tension  of  the  child's  muscles.  Oppor- 
tunities to  relieve  the  bladder  and  rectum  are  most  important,  and 
should  be  provided  for.  Sometimes,  through  timidity,  the  child  will 
fail  to  obey  such  calls  until  reduced  to  an  agony  of  nervousness.  There 
are  also  too  many  hours  of  home  study;  the  child  needs  most  of  these 
hours  for  play  or  family  association;  and  during  her  hours  out  of 
school  the  little  girl  should  not  be  taxed  with  sewing,  knitting,  painting, 
or  too  many  piano  lessons.  The  free  hours  would  be  far  better  occupied 
in  winter  by  gymnastics  or  skating,  and  in  summer  by  swimming  or 
cycling. 

During  the  long  summer  vacation  the  child  should  not  be  obliged 
to  carry  out  a  course  of  study  prescribed  by  the  school  before  closing, 
such  as  the  reading  of  certain  stipulated  books,  the  writing  of  compo- 
sitions, etc.  As  a  rule,  school  teachers  fully  appreciate  the  importance 
of  hygienic  measures,  but  cannot  personally  apply  these  principles  to 
the  welfare  of  the  pupils.  In  the  early  morning  hours  the  mind  is  most 
alert  to  permanent  impressions,  the  muscles  most  capable  of  doing 
their  hardest  tasks.  After  the  first  fatigue  drop  at  noonda}'  the  blood 
tension  and  temperature  increase  steadily  until  their  highest  point 
at  6  P.M.  From  this  time  on  the  natural  craving  of  adult  or  child  is 
for  rest  and  sleep.  Sleep  is  necessary;  even  the  young  mammal  toward 
evening  will  suckle  or  eat,  then  play,  and  settle  itself  to  sleep. 

High  blood-pressure  we  know  precludes  sleep ;  yet  in  this  period  the 
plastic  body  of  the  child  often  suffers  lasting  injury  by  being  driven 
to  evening  study.  Thus  we  defeat  the  very  purpose  toward  which  all 
education  is  directed — namely,  the  production  of  the  highest  degree 
of  efficiency.  The  system  of  cramming  for  examinations,  which  so 
closely  follow  each  other  as  to  be  no  gauge  of  the  child's  advancement, 
is  another  pernicious  factor  that  adds  to  the  general  high  tension. 
The  fact  seems  to  be  often  overlooked  that  there  is  an  education  higher 
and  far  better  calculated  to  fit  the  child  for  life  than  the  mere  imparting 
of  a  mass  of  facts.  The  inculcation  of  moral  principles,  which  the 
child  may  have  no  opportunity  of  learning  elsewhere,  forms  a  much 
more  stable  foundation. 

The  physical  conditions  upon  which  the  activity  of  the  mind  depends 
are  very  complex,  and  it  certainly  seems  only  reasonable  to  believe 
that,  during  the  years  in  which  the  bodily  growth  is  most  rapid, 
there  should  be  a  corresponding  reduction  in  the  amount  of  mental 
and  physical  work  imposed  upon  the  child.  This  is  necessary  even 
if  the  child  is  apparently  perfectly  able  mentally  and  physically  to  do 
the  work. 


.30  NORMAL  DEVELOPMENT  OF   THE   CHILD 

It  is  an  interesting  fact  that  bright  bo3's  are,  as  a  rule,  taller  and 
heavier  than  dull  boys,  and  it  is  also  well  established  that,  as  the  age 
increases,  brilliancy  in  most  studies  decreases,  and  that  the  ability  to 
learn  and  absorb  quickly  is  an  attribute  of  the  young.  Normal  children 
should  be  studied  more,  and  the  normal  standard  is  best  ascertained 
by  the  careful  study  of  the  physical  statistics  of  a  large  number  of 
children.  These  are  often  of  great  value,  and  frequently  furnish 
important  information  both  to  the  physician  and  educator.  Special 
attention  is  necessary  during  the  two  years  before  puberty,  as  in  both 
boys  and  girls  this  is  the  period  of  most  rapid  growth  in  both  height 
and  weight,  the  age  being  from  tAvelve  to  fourteen  years  for  girls  and 
from  fourteen  to  sixteen  for  boys. 

Height. — Heredity  is  a  distinct  factor  in  height,  the  children  of 
tall  parents  being,  as  a  rule,  taller  than  those  of  short  parents. 
Rachitic  children  are,  as  a  rule,  shorter  than  those  of  the  same  age 
who  are  not  rachitic.  It  is  also  of  interest  to  note  that  often  during 
acute  febrile  conditions  the  child  may  show  a  rapid  growth  in  length, 
notwithstanding  a  decided  loss  in  weight,  malnutrition  evidently 
affecting  the  weight  but  not  the  height.  Children  grow  most  rapidly 
during  the  first  year,  and  especially  during  the  first  three  months  of 
.life.  The  average  length  of  boys  at  birth  is  19f  inches  (49.5  cm.), 
and  of  girls  slightly  less,  19j  inches  (-18  cm.).  During  the  first  two 
years  the  growth  is  about  the  same  for  both  girls  and  boys.  From  the 
third  to  the  twelfth  year  girls  grow  more  slowly  than  boys.  After  the 
twelfth  year,  owing  to  the  earlier  advent  of  puberty,  the  girl  grows 
more  rapidly  and  overtakes  the  gain  made  by  the  boy.  The  boy 
develops  the  more  rapidly  from  the  fourteenth  to  the  sixteenth  year, 
and  again  passes  the  girl  in  height. 

The  growth  of  the  child  during  the  first  year  is  8  inches  (20  cm.), 
in  the  second  year  4  inches  (10  cm.),  in  the  third  year  3.2  inches  (8  cm.), 
in  the  foiu-th  year  2.8  inches  (7  cm.),  from  the  fifth  to  the  eleventh 
year  the  child  grows  from  2  to  2|  inches  (5  to  6  cm.)  each  year,  and 
at  the  age  of  puberty  both  girls  and  boys  grow  from  2  to  3  inches 
(5  to  7.5  cm.)  each  year  for  two  or  three  years. 

During  the  day  the  child  decreases  in  height  and  gains  in  weight, 
during  the  night  he  increases  in  height  and  loses  in  weight. 

At  the  age  of  five  years  the  child  is  twice  as  tall  as  at  birth,  and  at 
fourteen  years  three  times  as  tall  as  at  birth. 

Insufficient  food  and  poor  hygienic  surroundings  usualh'  retard  both 
growth  in  height  and  weight;  whereas  acute  illness  often  results  in  a 
growth  in  height,  notwithstanding  a  loss  in  weight. 

Weight. — A  delicate,  premature,  or  undersized  infant  should  be 
weighed  every  day;  infants  of  normal  weight  at  birth  should  be  weighed 
twice  a  week  during  the  first  six  months,  during  the  second  six  months 
once  a  week,  during  the  second  year  every  two  weeks,  and  a  careful 
record  should  be  kept  of  these  weighings.  It  is  necessary  to  appreciate 
that  a  gain  in  weight  does  not  always  signify  an  improvement  in 
the  general,  physical,  and  nervous  condition.    The  tissues  may  be  soft 


WEIGHT  31 

and  flabby,  the  bones  rachitic,  the  child  anemic  and  neurotic,  and  yet 
the  scales  indicating  a  gain  in  weight  might  divert  one's  attention  from 
these  conditions,  unless  care  is  taken  to  note  that  a  gain  in  weight  to 
be  satisfactory  must  go  hand  in  hand  with  normal  development  in 
every  other  respect. 

If  fed  on  high  percentages  of  starches  and  sugars,  they  may  gain 
in  weight  but  the  tissues  are  apt  to  be  soft  and  flabby.  The  importance 
of  a  failure  to  gain  in  weight  is  evident.  It  signifies  either  that  the 
different  food  elements  are  deficient  in  quantity  or  quality  properly 
to  nourish  the  infant,  or  that  all  or  one  of  them  is  not  adapted  to  the 
child's  digestive  powers;  again,  the  child  may  be  digesting  its  food 
properly,  but  some  other  condition,  such  as  fever  or  loss  of  sleep,  may 
be  so  increasing  the  metabolic  processes  that  no  gain  in  weight  results. 

In  other  cases  the  quantity  and  quality  of  the  food  offered  may  be 
correct,  but  the  infant  fails  to  take  a  sufficient  amount.  Bottle-fed 
babies  are  much  more  likely  to  develop  gastro-intestinal  disturbances 
than  those  who  are  breast-fed,  and  the  problem  of  a  child  with  station- 
ary or  decreasing  weight  must  be  studied  from  the  stand-point  of  that 
individual  child,  and  the  dift'erent  causes,  such  as  food,  the  personal 
and  family  history,  hygienic  surroundings,  gastro-intestinal  or  other 
diseases  considered.  The  weight  curve  of  the  bottle-fed  baby  is  usually 
below  that  of  the  breast-fed  infant,  and  irregularities  in  this  curve  are 
more  frequent. 

In  order  to  avoid  errors  in  the  weight  chart  a  child  should  always  be 
weighed  in  the  same  clothes,  the  fewer  the  better,  on  the  same  scales  and 
at  the  same  time  of  day.  The  lightest  weight  is  usually  reached  by  the 
third  day,  the  loss  in  weight  during  the  first  three  days  being  accounted 
for  largely  by  the  small  amount  of  breast  milk  received  by  the  infant 
and  the  loss  of  meconium  and  urine.  During  these  first  few  days  water 
should  be  given  freely,  and  while  it  is  not  wise  during  this  period,  either 
from  the  stand-point  of  the  child  or  the  mother,  to  force  it  to  nurse  too 
frequently,  still  it  is  a  well-established  fact  that  the  sooner  the  child 
begins  to  receive  an  abundant  supply  of  breast  milk  the  sooner  does 
this  initial  loss  of  w^eight  cease. 

The  presence  of  the  colostrum  corpuscles  is  also  an  element  in  the 
weight  loss,  as  the  loss  of  weight  is  largest  when  the  colostrum 
corpuscles  persist.  The  average  loss  during  these  first  three  days  is 
about  six  to  eight  ounces,  and  this  should  all  be  regained  by  the  end 
of  the  first  week.  If,  after  the  third  day,  the  weight  still  continues  to 
fall,  or  even  remains  stationary,  it  points  to  either  a  deficient  secretion 
of  breast  milk  or,  perhaps,  some  abnormal  condition  in  the  infant  of  an 
inherited  or  acquired  character — among  the  former  syphilis  or  some 
congenital  malformation,  among  the  latter  sepsis  and  gastro-intestinal 
or  pulmonary  disease.  Such  a  child  must  be  studied  most  carefully 
in  order  as  early  as  possible  to  correct  or  at  least  modify  the  cause  of 
its  failure  to  gain.  This  is  of  importance,  as  an  unnatural  loss  of  weight 
during  the  first  few  days  or  weeks  of  life  is  often  regained  very  slowly 
and  with  difficulty. 


32 


NORMAL  DEVELOPMENT  OF   THE  CHILD 


The  normal  increase  in  weight  in  the  child  during  the  first  year  is 
remarkable.  It  should  double  its  birth  weight  when  five  months  old, 
and  treble  it  at  one  year.  The  infant  starting  with  a  small  initial  birth 
weight  has  less  vitality  than  the  heavier  baby,  the  rule  being  that 
the  greater  the  weight  the  greater  the  vitality.  Ordinarily  the  baby 
small  at  birth  will  present  during  its  first  year  a  weight  chart  with 
a  lower  curve  than  the  one  shown  by  the  infant  heavier  at  birth.  To 
this  rule  there  are,  however,  many  exceptions,  as  it  is  quite  common  to 
find  the  child  small  at  birth,  if  normal  and  healthy,  gaining  so  rapidly 
in  weight  that  at  five  months  and  one  year  its  weight  is  equal  to  the 
normal  weight  of  the  infant  heavier  at  birth.  The  accompanying 
chart  (Fig.  1)  shows  the  usual  weight  curve  during  the  first  two 
year  in  a  child  of  average  birth  weight. 


MONTHS  OF  AGE 

1 

o 

3 

4 

5 

6      i       7 

8 

9 

10          11 

12 

1 
i 

4  1 

61 

8  202 

i2i 

WEEKS  OF  AGE 

2    4 

G     8 

10  12 

14  16 

18  20 

2*2  24  2G  28 

30  32  34 

SG  38 

40  42  14  4«  |48  50  5 

12258 

10890 

9980 
9530 
9070 
B620 
8160 
7710 
72  PO 
68U0 
6350 
5900 
5440 
4990 

4080 

LBS. 

28 
•a7 
26 

24 

22 

20 

18 

16 

15 
14 

10 
8 

■ 

- 

' 

^ 

'1 

- 

- 

I— 

-• 

^ 

— 

-■ 

^ 

■ 

U- 

' 

y 

1 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

._ 

_ 

_ 

_ 

_ 

Li- 

_ 

L 

L 

LJ_ 

L. 

L 

_ 

L 

ul 

Fig.  1. ^Weight  chart. 


•  This,  of  course,  represents  only  the  average  weight.  There  is, 
however,  a  distinct  tendency  for  both  the  light  and  heavy  infant 
at  birth  to  conform  closely  to  this  curve,  provided  the  child  is  normal 
and  healthy.  This  rapid  gain  in  weight,  in  conjunction  with  the 
great  amount  of  heat  lost  by  the  infant's  body,  necessitates  an  amount 
of  food  which  is  proportionately  large  for  the  child's  age,  especially 
when  one  considers  the  excessive  metabolism  of  the  growing  baby. 
The  production  of  heat  required  by  an  infant  is  much  greater  in 
proportion  than  that  required  by  the  adult,  because  the  infant  has 
a  smaller  body  but  a  greater  skin  surface  relatively  than  the  adult. 
If  this  heat  is  not  produced,  the  body  temperature  of  course  cannot 
be  maintained.  ^ 

The  weight  gained  during  the  second  year  is  six  pounds,  the  third 
year  four  and  one-half  pounds,  the  fourth  year  three  and  one-half 
pounds,  from  the  fourth  to  the  eighth  year  four  pounds  each  year, 
and  from  the  eighth  to  the  eleventh  year  six  pounds  each  year. 

The  following  tables  give  the  average  height  and  weight  of  both 
boys  and  girls  from  birth  to  sixteen  years: 


WEIGHT 


33 


HEIGHT. 

Age.  Boys. 

Birth 1954  inches 

lyear 28^ 

2  years '      .      32)^ 

3  "       . 

4  " 

5  " 


9 
10 
11 
12 
13 
14 
15 
16 


Age. 

Birth      . 
5  months 

1  year 

2  years 

3  " 

4  " 

5  " 

6  " 

7  " 

8  " 

9  " 

10  " 

11  " 

12  " 

13  " 

14  " 

15  " 

16  " 


35 

38 

41 

431^ 

453^ 

471^ 

493^ 

51K 

53H 

55 

58 

60 

63 

65 


WEIGHT. 

Boys. 
7  pounds  8  ounces 

15 

21 

27 

32 

37 

41 

45 

49 

54 

60 

66 

72 

79   "   12  ounces 

88 

97 
108 
119 


Girls. 

1934  inches 

28 

32>i       '• 

343^       " 

37M      " 

40M      " 

4314      " 

4514      " 

47 

4914      " 

513^      " 

53^      " 

553^      " 

58H      " 

60 

61M      " 

62 

Girls. 

7  pounds  2  ounces 

14 

4        " 

20 

6       " 

26 

" 

31 

" 

36 

4       " 

40 

" 

44 

" 

48 

" 

52 

"       8       " 

58 

"       8       " 

64 

" 

70 

4       " 

80 

" 

90 
100 

u 

108 
113 

« 

The  child  who  is  increasing  normally  in  weight  is  twice  as  heavy  at 
the  age  of  six  years  as  it  was  at  one  year,  and  at  the  age  of  thirteen 
years  has  doubled  the  weight  of  six  years. 

The  failure  of  an  infant  to  gain  in  weight  is  often  the  first  indication 
to  the  physician  that  the  child  is  not  developing  normally,  and  should 
be  a  sufficient  reason  for  making  a  careful  examination  of  the  infant's 
food  and  life;  if  the  examination  is  successful  the  cause  of  this  failure 
to  gain  will  be  discovered,  perhaps  long  before  any  evidence  of  de- 
ficiency in  the  quantity  or  quality  of  the  food,  or  any  signs  or  symptoms 
of  indigestion  or  other  illness  have  become  sufficiently  marked  to 
attract  attention.  In  fact,  it  is  impossible  for  any  one  to  decide 
except  by  the  use  of  the  scales  just  what  progress  the  baby  is  making, 
and  the  failure  to  weigh  the  baby  systematically  often  accounts  for 
nutritional  disorders  being  unnoticed  and  not  treated  sufficiently 
early. 

With  the  possible  exception  of  the  first  two  years  of  life,  the  growth 
which  occurs  at  puberty  is  the  most  important.  It  is  the  time  of  the 
3 


34  NORMAL  DEVELOPMENT  OF   THE  CHILD 

most  rapid  growth  and  development  of  the  entire  body,  of  the  greatest 
increase  in  both  height  and  weight,  and  at  this  period  we  find  also  the 
most  rapid  development  in  chest  measm'ements,  in  lung  capacity, 
and  in  the  muscles  of  the  arms  and  legs. 

The  custom  of  putting  children  to  work,  especially  in  ill-ventilated 
apartments,  during  this  critical  period  cannot  be  too  strongly  con- 
demned, as  such  children  invariably  show  subnormal  development. 
Statistics  carefully  collected  on  a  large  scale  in  England  prove  that  in 
children  who  work  half  time  in  the  mills  subnormal  development  is  as 
follows:  At  the  age  of  eleven  years,  7.5  per  cent.;  twelve  years,  11.2 
per  cent.;  thirteen  years,  15.7  per  cent.;  fourteen  years,  19  per  cent.; 
fifteen  years,  26.5  per  cent.  Could  anyone  wish  a  more  striking  example 
of  the  injurious  effects  of  child  labor? 

Head. — At  birth,  especially  if  labor  has  been  difficult  or  prolonged, 
the  infant's  head  is  often  elongated  in  its  anteroposterior  diameter. 
This  condition,  the  result  of  pressure  during  labor,  is  usually  of  no 
pathological  significance,  and,  as  a  rule,  disappears  in  the  course  of  a 
few  weeks.  The  larger  the  child  the  larger  should  be  the  head;  and, 
while  a  certain  amount  of  variation  from  the  normal  may  be  of  no 
special  importance,  still  an  infant's  head  considerably  above  the 
normal  size  should  at  least  suggest  the  possibility  of  hydrocephalus, 
rickets,  or  possibly  cretinism. 

If  the  infant  is  much  below  normal  weight  its  head  will,  of  course,  be 
smaller  than  normal,  and  this  is  the  case  in  premature  infants,  al- 
though in  premature  infants  the  head  is  large  in  proportion  to  the 
thorax.  A  head  much  smaller  than  normal  in  a  well-developed  baby 
at  full  term  should  suggest  microcephalus,  and  possibly  mental 
deficiency.  In  deciding  as  to  the  probability  of  the  head  being  of 
normal  size,  it  must  be  borne  in  mind  that  the  maximum  circumference 
of  the  head  and  of  the  thorax  during  the  first  two  years  of  life 
correspond  very  closely.  After  this  period  the  chest  increases  more 
rapidly  in  size,  as  is  shown  by  the  following  table: 

Circumference  of  head  Circumference  of  thorax 

At  birth 13.5  inches  12.5  inches 

6  months 17.0       "  16.5       " 

1  year 18.0      "  18.5      " 

18  months 18.5       "  19.0       " 

2  5^ears 19.0       "  19.5       " 

5      " 20.5       "  21.5       " 

10      " 21.0       "  25.0       " 

15      " .     22.0      "  30.0      " 

The  anterior  fontanelle  always  exists  at  birth,  and  may  ^'ary  in  size 
from  one-half  to  two  inches  laterally,  and  from  two  to  three  inches 
longitudinally.  It  changes  very  little  in  its  diameters  until  the  ninth 
month,  when  it  gradually  begins  to  unite,  and  is  usually  entirely 
closed  by  the  eighteenth  month.  If  the  child  is  robust,  and  the  head  of 
normal  size,  the  early  closure  of  the  fontanelle  usually  is  of  no  signifi- 
cance.    The  failure  of  the  suture  to  close  until  a  few  months  later 


THYMUS   GLAND  35 

than  normal  may  simpl}'  indicate  malnutrition;  but,  if  the  head  is 
unnaturally  large,  may  point  to  rickets,  hydrocephalus,  or  cretinism. 

Owing  to  the  lack  of  ossification  the  bones  of  the  skull  in  the  infant 
are  very  soft  and  the  skull  may  even  become  misshapen  by  allowing 
the  infant  to  lie  continually  on  one  side. 

The  principal  sutures  of  the  head  are,  as  a  rule,  ossified  at  the 
seventh  month,  although  a  delay  of  one  or  two  months  is  of  no 
special  significance. 

Neck.^ — A  casual  examination  gives  one  the  impression  that  the  neck 
of  the  infant  is  short.  In  reality  the  cervical  portion  of  the  bony  spine 
is  longer  proportionately  than  in  the  adult.  The  apparent  shortness 
is  due  to  the  high  position  of  the  sternum,  the  large  deposit  of  super- 
ficial fat  in  this  region  in  the  infant,  and  the  failure  of  the  young  child 
to  hold  its  head  erect. 

Spine.— In  the  young  infant  the  spinal  column  presents  the  sacral 
curve  and  a  long  posterior  curvature  or  convexity  extending  above 
the  sacrum.  The  normal  spinal  curves  develop  as  age  advances,  the 
curve  in  the  cervical  region  appearing  when  the  baby  is  able  to  hold  its 
head  erect,  and  the  curves  in  the  lumbar  and  dorsal  spine  developing 
when  the  child  is  able  to  walk.  The  spinal  cord  descends  to  the  third 
lumbar  vertebra  in  the  young  infant,  a  point  lower  by  one  vertebra 
than  its  lowest  point  in  the  adult. 

The  spine  in  the  infant  and  young  child,  owing  to  the  large  amount 
of  cartilage  and  comparatively  small  amount  of  bone  cells,  is  very 
flexible,  and  can  therefore  bend  or  be  bent  to  a  degree  much  greater 
than  is  possible  in  the  adult.  Its  greater  flexibility  and  lack  of  ossi- 
fication render  it  more  susceptible  to  slight  and  temporary  influences 
of  an  injurious  nature  than  is  the  case  with  the  adult  bony  spine,  and 
predispose  the  infant  and  young  child  to  spinal  deformities.  A  line 
drawn  between  the  anterosuperior  spinous  processes  of  the  ilia  passes 
over  the  spine  of  the  fourth  lumbar  vertebra,  and  is  a  useful  landmark 
in  lumbar  puncture. 

Thymus  Gland. — The  thymus  develops  during  fetal  life  from  the 
third  visceral  pouches  on  either  side,  and  thus  forms  a  bilaterally 
symmetrical  tubular  organ  stretching  out  between  the  th\Toid  and 
upper  limits  of  the  heart.  The  epithelial  elements  are  more  and  more 
encroached  upon  by  surrounding  vascular  and  lymphatic  tissue, 
so  that  at  birth  the  gland  consists  largely  of  the  latter,  containing 
only  epithelial  remnants  in  the  form  of  so-called  Hassal's  corpuscles. 
The  thymus  gland  grows  up  to  the  second  or  third  year  of  life,  when  its 
weight  varies  between  7  and  27  grams  (0.2  and  0.9  of  an  ounce); 
Friedleben  gives  it  at  27  grams  as  compared  with  14  grams  (0.5  of  an 
ounce)  at  birth.  iVtrophy  of  the  thymus  begins  after  the  second  or 
third  year  and  progresses  slowdy  until  puberty.  From  puberty  to 
early  adult  life  the  atrophy  progresses  rapidly,  and  at  adult  life  very 
little  thymus  tissue  remains. 

The  thymus  consists  usually  of  two  flat  slender  lobes  joined  in  the 
middle  by  delicate  connective  tissue.     It  moves  up  and  down  with 


36  NORMAL  DEVELOPMENT  OF   THE  CHILD 

respiration.  At  birth  it  is  of  a  faintly  red  color,  moderately  soft, 
and  looseh^  enclosed  in  a  thin  capsule  which  in  its  turn  is  closely 
connected  with  the  surrounding  structures,  the  trachea,  the  arch  of 
the  aorta,  the  pulmonary  artery,  the  superior  vena  cava,  both  in- 
nominate veins,  the  recurrent  and  pneumogastric  nerves,  also  the 
upper  part  of  the  epicardium  and  the  apices  of  the  lungs.  The  gland 
usually  reaches  up  into  the  episternal  notch,  but  not  necessarily  so, 
even  when  enlarged.  Its  close  proximity  to  so  many  important  organs, 
and  the  fact  that  the  distance  between  the  manubrium  and  the  verte- 
bral column  in  infants  is  little  more  than  2  cm.,  accounts  for  the  very 
serious  disturbance  which  may  arise  from  an  abnormal  enlargement 
of  the  thymus. 

The  thj^mus  is  a  ductless  gland  supplied  by  the  vagus  and  sym- 
pathetic nerves.  Researches  as  to  its  function  are  not  yet  conclusive. 
During  the  last  fetal  months  it  plays  a  part  in  the  making  of  blood. 
It  is  claimed  also  that  it  has  an  internal  secretion  similar  to  that  of 
the  thyroid  which  influences  the  general  growth  and  development 
of  bones,  and  perhaps  also  the  blood-pressure.  Complete  extirpation 
of  the  gland  in  dogs  has  resulted  in  osteoporosis,  osteomalacia,  and 
rachitis,  possibly  as  a  result  of  acid  intoxication  which  has  interfered 
with  a  deposit  of  lime  salts  in  the  bones  or  has  dissolved  some  already 
deposited. 

The  condition  of  the  thymus  gland  seems  also  to  be  an  index  of  the 
general  condition  in  infants,  as  in  IS  cases  of  marasmus  the  average 
weight  of  the  gland  was  found  at  autopsy  to  be  only  2.2  grams  (33.9 
grains)  as  against  18  grams  (three-fifths  of  an  ounce)  in  the  normal. 
As  a  possible  explanation  of  idiotica  thymica,  it  seems  interesting  that 
Bourneville  at  postmortem  found  the  gland  absent  in  25  out  of  28 
mentally  weak  children. 

Thorax. — ^The  chest  of  the  child  is  barrel-shaped  and  gradually 
changes  to  a  dome-shape  at  puberty.  The  anteroposterior  and  trans- 
verse diameters  are  nearly  equal  at  birth,  but  after  the  third  year 
the  transverse  increases  more  rapidly  up  to  puberty  than  the  antero- 
posterior. The  lungs,  on  account  of  the  shape  of  the  chest,  lie  more 
posteriorly  than  in  the  adult.  The  walls  are  very  elastic,  as  the  spine, 
ribs,  and  sternum  are  largely  cartilaginous.  The  chest  walls  are  also 
thinner,  owing  to  their  slight  muscular  development;  and  in  normal 
infants  the  superficial  tissues  are  composed  largely  of  fat.  The  high 
position  of  the  diaphragm,  the  large  thymus,  and  possibly  dilated 
stomach  and  bowels  tend  to  lessen  the  size  of  the  thorax. 

In  newborn  infants  the  maximum  circumference  of  the  chest  is 
about  three-fourths  to  one  inch  less  than  the  maximum  circumference 
of  the  head;  at  six  months  it  is  one-half  inch  less  than  the  head; 
but  at  one  year  the  thorax  not  only  equals  the  head  in  size,  but 
its  maximum  circumference  is  now  one-half  inch  greater  than  the 
head.  During  the  first  three  years  the  difi^erence  in  the  size  of  the  head 
and  thorax  is  xery  slight,  a  fact  which  is  often  of  assistance  in  suspected 
microcephalic  or  hydrocephalic  conditions.     A  very  fat  child  will,  of 


FETAL  CIRCULATION  37 

course,  have  a  large  chest;  on  the  otlier  luiiid  a  small  thorax  should 
always  be  looked  ii])oii  as  an  indication  of  inii)erfect  develoj)inent, 
and  should  suggest  the  necessity  for  regulated  calisthenics.  Kickets, 
empyema,  emphysema,  cardiac  disease,  and,  in  older  children.  Pott's 
disease  or  lateral  spinal  curvature,  cause  more  or  less  thoracic  deform- 
ity. "Trichter-brust"  is  a  funnel-shaped  depression  at  the  lower  end 
of  the  sternum.  It  may  be  congenital  or  the  result  of  rickets;  in  the 
former  case  the  lower  end  of  the  sternum  is  very  much  retracted ;  in 
the  latter  other  evidences  of  rickets  are  usually  present. 

If  after  the  second  year  the  chest  is  smaller  than  the  head,  it  may 
indicate  that  the  head  is  enlarged,  as  in  rickets  or  hydrocephalus,  or 
the  unnatural  smallness  of  the  chest  may  be  the  result  of  disease  of 
the  lungs  or  of  some  interference  with  respiration,  such  as  may  be 
produced  by  adenoids.  A  long,  narrow,  and  fiat  chest  suggests  the 
tubercular  type,  while  a  pigeon-shaped  breast  points  to  rachitis, 
an  asymmetrical  chest  suggests  pleural  effusion,  pneumothorax,  or 
scoliosis,  while  precordial  bulging  may  indicate  heart  disease. 

From  birth  until  the  seventh  year  the  most  noticeable  change  in  the 
thorax  is  the  increase  in  its  tranverse  diameter;  during  these  years 
the  chest  also  greatly  increases  in  its  vertical  length,  while  from  the 
sixth  to  the  ninth  year  the  vertical  diameter  develops  more  rapidly 
than  the  transverse.  At  puberty  there  is  again  a  rapid  increase  in  the 
vertical  diamxeter,  especially  in  boys.  The  infant's  shoulders  are  small 
and  the  ribs  more  nearly  horizontal  than  in  the  adult.  By  the  end  of 
the  second  year  the  sternum  has  a  number  of  centers  of  ossification, 
but  is  still  largely  cartilage;  the  manubrium  and  gladiolus  are  fairly 
well  ossified,  while  the  ensiform  cartilage  ossifies  more  slowly. 

Fetal  Circulation.— The  circulation  in  utero  is  carried  on  without 
any  oxygenation  of  the  blood  by  the  lungs  of  the  fetus.  The  oxy- 
genated blood  from  the  placenta,  carried  by  the  umbilical  vein,  enters 
the  fetus  at  the  umbilicus,  and  then  passes  to  the  under  surface  of  the 
liver  of  the  fetus  where  it  gives  off  two  or  three  branches  to  the  left 
lobe.  Farther  on,  at  the  transverse  fissure,  it  divides  into  two  branches, 
the  larger  of  these  joining  the  portal  vein  and  entering  the  right  lobe; 
the  smaller,  the  ductus  venosus,  joining  the  left  hepatic  vein  at  the 
point  where  the  latter  empties  into  the  inferior  vena  cava.  All  the 
blood  entering  the  fetus  by  the  umbilical  vein  except  that  portion  which 
passes  through  the  ductus  venosus  traverses  the  liver,  and  empties 
by  the  hepatic  veins  into  the  inferior  vena  cava. 

The  inferior  vena  cava,  which  contains  also  the  blood  deoxidized  by 
its  passage  through  the  lower  extremities,  empties  into  the  right 
auricle,  and,  guided  by  the  Eustachian  valve,  passes  through  the 
foramen  ovale  into  the  left  auricle.  Here  it  mixes  with  the  small 
quantity  of  blood  which,  having  served  to  nourish  the  lungs,  is  emptied 
by  the  pulmonary  veins  into  the  left  auricle.  The  blood  passes  from 
the  left  auricle  through  the  mitral  orifice  to  the  left  ventricle,  and  from 
the  left  ventricle  through  the  aortic  valves  into  the  aorta,  and  is  in 
large  part  conveyed  by  the  carotid  and  subclavian  arteries  to  the  head 


38  NORMAL  DEVELOPMENT  OF   THE  CHILD 

and  iij)|)tT  extremities  wliieli,  lliiis  receiving'  the  major  portion  of  the 
oxygenated  blood,  are  especially  well-developed  at  birth.  A  small 
portion  of  this  blood,  however,  passes  into  the  descending  aorta. 

The  blood  from  the  head  and  upper  extremities  is  returned  by  the 
veins  to  the  superior  vena  cava  and  into  the  right  auricle,  where  it 
mixes  with  a  small  portion  of  the  blood  emptied  into  the  right  auricle 
by  the  inferior  vena  cava,  the  major  portion  of  this  latter  blood  having 
passed  directly  through  the  foramen  ovale  into  the  left  auricle.  The 
small  portion  of  blood  from  the  inferior  vena  cava  that  does  not  pass 
through  the  foramen  ovale,  mixing  with  the  blood  that  enters  the  right 
auricle  by  the  superior  vena  cava,  passes  through  the  tricuspid  orifice 
into  the  right  ventricle,  and  from  the  right  ventricle  into  the  pulmonary 
artery. 

As  the  lungs  require  only  a  small  portion  of  blood  to  nourish  them, 
the  amount  distributed  to  them  b}'  the  right  and  left  pulmonary  arteries 
is  not  large,  and,  after  performing  its  function  of  nourishing  the  lungs, 
it  empties  into  the  left  auricle  by  the  pulmonary  veins.  The  major 
portion  of  the  blood  entering  the  pulmonary  artery  passes  through  the 
ductus  arteriosus  into  the  descending  aorta,  mixing  with  the  small 
quantity  of  blood  which  passes  into  the  aorta  from  the  left  ventricle. 
This  blood  containing  a  small  proportion  of  oxygen  passes  down 
and  supplies  the  viscera  of  the  abdomen  and  pelvis  and  the  lower 
extremities,  the  major  portion  of  it,  however,  being  conveyed  by  the 
umbilical  arteries  to  the  placenta,  where  it  is  again  oxygenated.  The 
small  portion  of  blood  passing  to  the  lower  extremities  explains  their 
comparatively  small  size  and  lack  of  development  at  birth. 

The  important  points  which  one  should  remember  in  the  infant 
and  fetal  heart  are:  (1)  the  opening  between  the  two  auricles,  and 
(2)  in  connection  with  this  opening  the  large  size  of  the  Eustachian 
valve.  Situated  as  it  is  on  the  left  side  of  the  opening  of  the  inferior 
vena  cava,  it  serves  to  guide  the  blood  through  the  foramen  ovale  from 
the  right  into  the  left  auricle. 

The  heart  of  the  newborn  occupies  a  vertical  position  until  the 
fourth  month.  After  this  period  it  gradually  assumes  an  oblique 
position.  Its  size  as  compared  with  the  body  is  at  birth  as  1  to  120, 
at  the  second  month  as  1  to  50,  and  in  adult  life  as  1  to  160.  Early 
in  fetal  life  the  auricles  are  larger  than  the  ventricles,  the  right  auricle 
being  larger  than  the  left.  Near  the  end,  however,  of  intra-uterine  life, 
the  ventricular  portion  becomes  the  larger,  the  left  ventricle  as  the 
period  of  birth  approaches  becoming  thicker  than  the  right. 

As  soon  as  the  child  breathes,  an  increased  amount  of  blood  from  the 
pulmonary  artery  passes  into  and  through  the  lungs,  and  they  at  once 
assume  the  function  of  oxygenating  the  infant's  blood. 

After  the  fifth  month  of  intra-uterine  life,  the  lumen  of  the  ductus 
arteriosus  gradually  decreases,  and  its  rapid  obliteration  as  a  blood- 
vessel is  therefore  quickly  accomplished  after  birth.  At  birth  only  a 
small  portion  of  blood  passes  through  the  ductus  arteriosus,  and  its 
lumen,  already  considerably  lessened,  quickly  becomes  obliterated, 


RESPIRATION  39 

no  blood  passing  through  it  after  the  sixth  to  the  tenth  day.  The 
foramen  ovale  rapidly  closes  and  becomes  practically  impervious  to 
the  passage  of  blood  at  about  the  tenth  day  after  birth.  A  small 
slit-like  opening,  however,  usually  persists  for  some  months;  in 
fact,  some  weeks  before  birth  the  foramen  ovale  gradually  becomes 
smaller  as  the  result  of  a  septum  which  is  slowly  closing  the  orifice. 
With  the  ligation  of  the  cord  the  blood  ceases  to  flow  through  the 
umbilical  arteries,  clots  form  in  each  artery,  and,  becoming  organized, 
result  in  the  closure  of  their  lumina.  The  umbilical  vein  is  also  obliter- 
ated, having  become  the  round  ligament  of  the  liver.  The  time  required 
to  complete  the  circulation  in  the  infant  is  at  birth  twelve  seconds, 
at  five  years  of  age  fifteen  seconds,  at  fourteen  j^ears  eighteen  seconds; 
in  the  adult  it  is  twenty-two  seconds. 

Pulse. — The  frequency  of  the  heart's  action  is  shown  in  the  following 
table : 

Pulse. 

Before  birth 150 

At  birth - 130  to  140 

First  year 115  to  130 

Second  year 100  to  115 

Third  year 90  to  100 

Fourth  to  seventh  year 85  to    90 

Seventh  to  fourteenth  year 80  to    85 

The  pulse,  if  possible,  should  always  be  taken  when  the  infant  is 
very  quiet,  or,  better,  if  asleep.  Under  perfectly  normal  conditions 
its  rate  varies  much  more  than  in  the  adult,  and  the  slightest  movement 
will  increase  the  rapidity  of  the  heart's  beat;  the  more  violent  the 
movement  or  excitement  the  greater  will  be  the  increase.  An  increase 
of  from  twenty  to  thirty  beats  in  the  minute  may  easily  follow  any 
excitement  or  unusual  exertion,  the  slightest  cause  being  enough 
to  disturb  the  rate  and  force.  The  rapidity  of  the  pulse  is  of  less 
significance  than  its  force.  An  infant  ill  from  any  cause  may  have  a 
pulse  of  150  to  175  or  even  higher  and  be  in  no  danger,  while  the  same 
pulse  rate  if  lacking  in  force  would  be  of  much  more  serious  conse- 
quence. The  pulse  wave  of  a  healthy  infant  shows  dicrotism,  which 
becomes  more  marked  in  cardiac  disease  and  in  all  acute  infectious 
diseases. 

Respiration. — Respiration  is  more  rapid  in  infancy  and  early  life 
than  in  the  adult,  although  it  tends  to  approach  the  adult  type  earlier 
than  does  the  pulse.  The  rhythm  during  infancy  varies  greatly,  even 
in  the  perfectly  normal  and  healthy  baby.  Respiration  in  the  infant 
is  of  the  abdominal  type,  the  muscles  of  the  chest  being  poorly 
developed,  while  the  muscles  of  the  abdomen  and  diaphragm  are 
well  developed.  The  abdominal  or  diaphragmatic  type  of  respiration 
persists  until  about  the  tenth  year  in  girls  and  the  eleventh  year  in 
boys,  when  it  gradually  tends  to  change  to  the  costal  type.  In  the 
infant  respiration  may  for  a  few  moments  be  quite  superficial,  perhaps 
changing  a  few  seconds  later  and  becoming  deep.  The  period  between 
inspiration  and  expiration  also  often  varies.    While  a  disturbance  of  the 


40  NORMAL  DEVELOPMENT  OF   THE  CHILD 

respiratory  rhythm  is  of  no  significance  in  infants,  and,  in  fact,  occurs 
regularly  in  the  normal  infant,  it  is  of  importance  to  appreciate  that 
this  is  a  phenomenon  of  infancy  only.  In  the  child  of  two  years  or 
older  a  disturbance  of  the  rhythm  or  the  rapidity  of  respiration  often 
suggests  the  possibility  of  brain  or  lung  disease.  Comparatively  slight 
causes — a  moderate  fever,  excitement,  violent  crying,  or  slight  muscular 
exertion — will  in  the  infant  cause  not  only  a  change  in  the  rhythm 
but  also  a  marked  increase  in  the  respiratory  rate. 
The  frequency  of  the  respiration  is  shown  in  the  following  table: 

At  birth 35  to  50  per  minute 

At  first  year 28  " 

At    2  years 25  " 

At    5      " 22 

At  10      " 18 

Temperature. — The  temperature  of  an  infant  or  small  child  should 
always  be  taken  in  the  rectum;  the  temperature  so  taken  is  more 
reliable  than  that  in  the  axilla- or  groin,  and,  owing  to  the  liability  of 
breakage,  the  method  is  safer  than  when  taken  in  the  mouth.  The  heat 
centre  in  the  young  is  evidently  not  fully  developed,  and  slight  causes 
easily  disturb  the  equilibrium  of  the  temperature.  It  is  almost  in- 
variably higher  in  infants  than  it  would  be  in  adults,  the  two  suffering 
from  the  same  disease.  Infants  produce  more  calories  in  proportion 
to  the  body  weight  than  adults,  but  give  off  more  heat  in  proportion 
to  their  size.  They  are,  therefore,  less  able  than  adults  to  stand 
extreme  cold. 

The  temperature  of  the  infant  falls  from  1.5°  to  2°  during  and 
after  the  first  bath,  and  requires  from  twelve  to  twenty-four  hours  to 
return  to  the  birth  temperature.  In  weak  or  premature  infants  the 
fall  may  exceed  1.5°  to  2°,  and  the  temperature  may  with  difficulty 
return  to  the  original  temperature  at  birth.  This,  of  course,  is  a  strong 
argument  for  the  omission  of  the  bath  in  such  children,  and,  in  addition, 
usually  indicates  the  necessity  for  the  employment  of  external  heat. 

Slight  variations  in  the  temperature  invariably  occur  even  in 
normally  developed  and  healthy  infants,  and,  if  not  exceeding  0.5°  F., 
are  of  no  significance.  The  bottle-fed  baby  ordinarily  shows  a  more 
irregular  temperature  than  the  infant  raised  at  the  breast.  During 
sleep  the  thermometer  often  registers  from  0.2  to  0.5  of  a  degreee  less 
than  when  the  infant  is  awake  and  active.  Very  slight  causes  or  mild 
illness  will  often  produce  in  the  infant  or  young  child  an  elevation 
of  from  1°  to  3°.  Excitement,  unusual  exertion,  crying,  or  too  many 
clothes  on  infants  in  hot  weather  will  often  cause  a  similar  rise. 

If  the  temperature  remains  continuously  high  it  usually  indicates 
some  serious  illness.  An  intermittent  temperature  may  or  may  not 
be  associated  with  illness  of  much  consequence.  It  is  extremely 
important,  however,  to  appreciate  that,  while  variations  in  temperature 
in  the  infant  may  be  and  often  are  produced  by  slight  causes,  one  must 
not  go  to  the  other  extreme,  and  become  careless  as  to  the  danger  which 
may  be  associated  with  such  changes. 


MUSCULAR  DEVELOPMENT  41 

Fever  may  occur  as  a  part  of  many  of  the  illnesses  from  which  an 
infant  or  young  child  is  suffering,  and  yet  the  symptoms  of  this  illness 
may  be  vague  and  uncertain.  The  fever  occurring  irv  measles  previous 
to  the  appearance  of  the  rash,  the  temperature  during  the  first  few  days 
of  typhoid,  and  the  fever  associated  with  otitis  media  may  be  of  great 
significance,  and  yet  the  symptoms  be,  possibly,  very  obscure.  The 
broad  rule  of  never  making  a  diagnosis  until  the  child  has  been  care- 
fully examined  from  head  to  foot,  not  forgetting  the  throat  and  skin, 
is  often  the  only  means  of  deciding  as  to  the  significance  of  a  fever. 

Subnormal  temperatures  are  sometimes  the  result  of  allowing  the 
thermometer  to  remain  too  short  a  time  in  position,  or  from  being 
taken  in  a  moist  axilla.  In  premature  or  delicate  infants  also  the  tem- 
perature is  often  below  the  normal,  and  in  cases  of  marked  malnutrition 
subnormal  temperatures  are  the  rule  and  not  the  exception.  The 
temperature  is  often  subnormal  in  children  with  congenital  and 
acquired  heart  disease.  In  older  children  a  subnormal  temperature 
is  associated  with  a  number  of  pathologic  conditions,  of  which  may 
be  mentioned  diabetes  insipidus  and  mellitus,  Addison's  disease,  and 
myxedema. 

It  is  an  interesting  fact  that  in  many  cities  the  maximum  outdoor 
temperature  occurs  at  2  to  3  p.m.,  and  that  the  maximum  temperature 
in  dwellings,  that  is,  indoors,  is  almost  always  at  its  height  at  a  con- 
siderable number  of  hours  after  2  to  3  p.m.,  perhaps  at  8  p.m.,  or, 
possibly,  well  into  the  night  or  early  next  morning  (3  a.m.).  Observa- 
tions taken  on  a  large  scale  in  poorly  ventilated  and  small  apartments 
show  that  under  such  conditions  the  maximum  temperature  indoors 
very  often  occurs  late  in  the  evening  or  late  in  the  night.  Children 
sleeping  in  such  rooms  should,  of  course,  never  be  bundled  up  even  if 
the  night  air  outside  is  cool. 

Muscular  Development.^ — While  the  muscles  of  the  infant  are  fairly 
well-developed,  coordination  does  not  exist.  Glycogen  is  present 
in  the  muscles  in  small  amounts,  about  0.5  of  1  per  cent,;  there  is  also 
a  small  amount  of  grape  sugar.  The  electrical  response  to  both 
galvanism  and  faradism  is  diminished  at  birth,  and  the  response  to 
electrical  stimulation  is  more  slowly  elicited,  the  period  of  latency  being 
longer.  Motion  is,  to  a  degree  at  least,  reflex,  and  is  more  or  less 
associated  with  a  sense  of  feeling  or  touch. 

During  birth  the  only  muscle  liable  to  injury  is  the  sternocleido- 
mastoid. In  breech  presentations  a  blood  clot  with,  perhaps,  a  tearing 
of  some  of  the  muscle  fibers  may  take  place.  A  swelling  the  size  of  a 
robin's  egg  may  be  noticed,  usually  on  the  anterior  aspect  of  the  muscle; 
it  is,  as  a  rule,  absorbed  spontaneously  in  the  course  of  a  few  weeks, 
although  shortening  of  the  muscle  and  torticollis  may  follow. 

The  hands  at  birth  seem  to  show  considerable  muscular  develop- 
ment, as  illustrated  by  the  strong  grasp  of  the  newborn  infant.  At 
three  months  the  infant  will  hold  its  head  erect  fairly  well,  and  at  the 
age  of  six  to  seven  months  it  can  be  placed  on  a  large  firm  mattress 
or  on  a  blanket  on  the  floor,  or,  still  better,  in  a  pen,  and  left  to  learn 


42  NORMAL  DEVELOPMENT  OF   THE  CHILD 

to  creep.  At  eight  or  nine  months  old,  if  normally  developed,  it  will 
have  acquired  the  power  to  move  its  body  from  one  place  to  another, 
either  by  rolling,  pushing,  or  creeping.  An  infant  should  always  lie 
on  a  firm  mattress,  and  often  be  placed  on  its  abdomen  as  well  as  on  its 
back,  and  invariably  be  loosely  dressed  so  as  to  allow  free  movements 
of  its  neck,  arms,  body,  and  legs. 

At  the  age  of  ten  months  a  child  usually  begins  to  grasp  a  chair  or 
the  side  of  its  crib  or  pen,  and  to  draw  itself  up  on  its  knees.  At  the 
age  of  twelve  months  it  should  be  able  to  walk  with  assistance.  Failure 
to  walk  at  twelve  or  thirteen  months  may  be  due  to  timidity,  poor 
bony  and  muscular  development,  or  to  mental  deficiency.  It  must  be 
remembered  that  it  is  wise  to  give  the  infant  all  possible  freedom  of 
movement  and  exercise,  and  to  alloW'  it  voluntarily  to  creep,  to  stand, 
and  to  w-alk.  Unusually  large  and  heavy  children  often  w-alk  late; 
this  may  be  more  to  their  advantage  than  otherwise,  as  their  bony 
and  muscular  systems  are  less  firm  and  resistant  than  normal,  hence 
less  able  to  support  the  child  in  the  upright  position. 

After  the  ability  is  acquired  to  stand  alone  some  children  quickl}^ 
learn  to  w^alk  alone;  others,  if  timid  or  not  very  robust,  may  not 
walk  alone  for  several  months  after  the  period  of  walking  with  assist- 
ance. In  my  opinion  it  is  rarely  necessary  or  advisable  to  encourage 
or  to  teach  a  child  to  walk.  A  child  normal,  physically  and  mentally, 
will  naturally  w-alk  as  soon  as  it  is  able  to  do  so;  in  fact,  the  tendency 
should  be  more  to  restrain  the  child  than  to  urge  it  on. 

Inability  to  grasp  objects  firmly  in  the  hand  at  birth,  to  reach  out 
for  objects  at  the  fomth  or  fifth  month,  to  hold  its  head  up  at  four  or 
five  months,  to  change  its  position  at  eight  or  nine  months,  to  sit 
up  at  one  year,  or  to  stand  at  fifteen  months,  means  usually  that  there 
is  some  physical  or  mental  defect,  and  should  at  least  make  it  impera- 
tive to  examine  most  carefully  into  the  mental  as  well  as  the  physical 
condition  of  the  child. 

According  to  Schlossmann,  the  infant  in  proportion  'to  the  weight  of 
its  body  performs  an  amount  of  work  about  equal  to  that  of  an  active 
adult,  and  the  food  required  by  an  infant  varies  as  does  the  food  of  an 
adult  in  direct  proportion  to  the  amount  of  muscular  work  performed. 

Nervous  System. — Until  the  last  few  months  of  fetal  life  the  cord 
extends  to  the  end  of  the  cervical  canal.  At  birth,  owing  to  the  more 
rapid  growth  of  the  bony  spine  during  the  last  few  months  of  intra- 
uterine life  as  compared  with  the  cord,  the  end  of  the  clonus  medullaris 
reaches  to  the  third  lumbar  vertebra.  In  the  adult  the  cord  terminates 
at  the  lower  end  of  the  first  lumbar  vertebra.  The  average  w- eight  of 
the  brain  in  the  healthy  newborn  child  is  12  to  13  ounces  (350  to  370 
grams),  and  increases  very  rapidly,  in  the  first  nine  months  of  life 
attaining  one-third  of  its  maximum  weight,  another  third  at  about 
the  age  of  two  and  a  half  years,  and  its  final  weight  at  about  the 
twentieth  year.  The  frontal  lobes  of  the  brain  of  the  newborn  are 
poorly  developed,  and  the  island  of  Reil  is  less  distinctly  outlined  than 
later  in  life.    Heredity  affects  especially  the  weight  of  the  cerebrum. 


SPECIAL  SENSES  43 

Tlie  c'crcbelluui  a\'eragcs  two-tliinls  of  an  oiiiur  (20  graiiisj  in  wcii^lit 
at  birth,  and  when  fnlly  developed  about  five  ounces  (140  grams). 
At  the  age  of  six  months  its  weight  increases  to  about  two  ounces 
(60  grams),  and  at  two  years  to  three  and  one-half  ounces  (100  grams). 
Its  subsequent  growth  is  much  slower  and  its  full  development  of 
five  ounces  (140  grams)  is  reached  at  about  the  same  time  as  that  of  the 
cerebrum,  20  years.  The  weight  of  the  boy's  and  man's  brain  is 
greater  than  that  of  the  girl's  and  woman's  brain  at  corresponding  ages. 

The  spinal  cord  of  the  newborn  averages  about  one-tenth  of  an  ounce 
(3  grams)  in  weight,  and  in  the  adult  about  nine-tenths  of  an  ounce 
(27  grams) .  It  weighs  two-tenths  of  an  ounce  (6  grams)  at  five  months, 
three-tenths  of  an  ounce  (9  grams)  at  one  year,  and  four-tenths  of  an 
ounce  (12  grams)  at  the  age  of  two  years. 

The  excitability  of  motor  nerves  and  muscles  is  very  faint  during 
the  first  two  months,  and  the  sensory  nerves  respond  very  slightly  to 
electrical  stimulation  during  this  period,  the  face  at  birth  being 
absolutely  irresponsive  to  this  stimulation.  At  birth  the  ganglion 
cells  lack  all  the  characteristic  adult  features,  this  being  most  marked 
in  the  cerebral  hemispheres.  Pigment  is  absent  at  birth  and  does  not 
develop  in  certain  portions  of  the  nervous  system  until  years  afterw^ard. 
At  the  age  of  one  year  brownish  pigment  is  deposited  in  the  locus 
cieruleus.  The  pigment  of  the  vagus  and  substantia  nigra  begins  to 
appear  at  the  fourth  year,  and  at  the  sixth  pigment  is  found  in  the 
posterior  spinal  ganglia,  but  does  not  appear  in  the  spinal  cord  until 
the  seventh  year. 

Many  nerve  fibers  do  not  develop  their  myelin  sheaths  until  after 
birth.  This  is  most  marked  in  the  cerebral  hemispheres;  for  while 
at  birth  the  full  proportion  of  myelin  is  present  in  the  spinal  cord,  the 
cerebrum,  cerebellum,  medulla,  pons,  and  quadrigeminal  bodies  pos- 
sess absolutely  no  myelin. 

In  the  fetus  of  eight  months  the  tactile  and  muscle  sense  tracts  are 
the  only  ones  supplied  with  myelin  sheaths.  At  full  term  the  pyramidal 
tracts,  the  olfactory,  the  visual  tracts,  and  the  corona  radiata  possess 
more  or  less  of  their  myelin  sheaths.  The  lack,  or  almost  total  absence, 
of  brain  function  at  birth  is  quite  likely  due  in  great  part  to  the  absence 
of  myelin  in  large  brain  areas.  The  tendon  reflexes  are  present  in  the 
premature  infant,  and  during  the  first  year  of  life  are  more  marked  than 
in  the  adult.  After  the  infant  is  ten  days  old  the  cutaneous,  abdominal, 
and  the  plantar  reflexes  are  very  active.  The  Babinski  reflex  is 
normally  present  during  the  first  six  or  eight  months  of  life. 

Special  Senses. — The  pupils  of  the  newborn  respond  normally  to 
light,  but  the  infant  is  not  believed  to  have  at  birth  the  power  to 
fix  objects,  and  the  power  of  accommodation  does  not  appear  until 
one  month  of  age.  The  reflex  closing  of  an  eyelid  at  the  approach  of  a 
finger  is  well  developed  at  birth,  but  the  true  optical  reflex  of  winking 
is  not  seen  until  about  the  seventh  week.  At  the  age  of  one  month 
the  child  is  capable  of  fixing  its  eyes  upon  an  object,  and  at  four 
months  can  follow  a  moving  object  with  its  eyes. 


44 


NORMAL  DEVELOPMENT  OF   THE  CHILD 


111  children  })orii  before  full  term  the  swelling  of  the  Eustachian 
tube  often  pre\'ents  the  (leveloj>ment  of  hearing  for  some  da^^s. 
Although  the  newborn  infant  cannot  hear,  the  ability  to  do  so  develops 
within  a  few  hours  to  several  days  after  birth,  hearing  depending  upon 
the  time  of  entrance  of  air  through  the  Eustachian  tube  into  the 
internal  ear. 

The  sense  of  taste  develops  early,  as  is  evidenced  by  the  fact  that  a 
very  young  infant  will  often  detect  slight  differences  in  its  food;  or 
will,  perhaps,  refuse  water  when  accustomed  to  having  a  small  amount 
of  sugar  added  thereto. 

The  sense  of  smell  is  little  if  at  all  developed  at  birth,  but  develops 
rapidly  in  the  first  few  days  of  life.  The  sense  of  touch  is  one  of  the 
first  to  appear,  and  is  alwaj's  present  at  birth,  the  tactile  tracts  being 
supplied  with  myelin  at  the  eighth  month  of  fetal  life.  Appreciation  of 
touch  is  especially  noticeable  in  the  lips,  the  introduction  of  any  object 
into  the  mouth  being  usually  sufficient  to  produce  the  reflex  act  of 
sucking.  The  newborn  infant  does  not  feel  pain,  is  quite  insensitive 
to  the  prick  of  a  pin,  and  is  probably  entirely  unable  to  appreciate  the 
difference  between  external  heat  and  cold,  although  heat  and  cold, 
as  in  the  douche  or  plunge,  exert  a  reflex  influence.  Sucking,  swallow- 
ing, and  ocular  movements  at  birth  probably  do  not  depend  upon  any 
conscious  mental  eft'ort,  but  are  largely  or  entirely  inherited  reflexes. 

Speech  begins  to  develop  at  about  the  tenth  month,  varying  more  or 
less  in  different  children,  and  depending  to  a  certain  extent  on  the 
child's  surroundings  and  management,  but  the  tendency  to  induce 
infants  to  talk  is  certainly  not  to  be  encouraged. 

Stomach. — When  the  stomach  is  empty  the  pylorus  occupies  the 
lowest  position,  being  found  in  the  continuation  downward  of  the  mid- 
sternal  line,  or  slightly  to  the  left  of  this  line.  The  cardia  occupies 
a  position  on  the  left  of  the  tenth  dorsal  vertebra,  and  is  about  one  to 
one  and  a  half  inches  (2  to  3.5  cm.)  above  the  pjdorus.  The  fundus  is 
usually  only  fairly  well  developed  at  birth,  and  the  capacity  of  the 
stomach  at  different  ages  is  represented  in  the  following  table: 


At  birth  .      .      . 

1      ounce 

At  two  weeks     . 

2      ounces 

At  one  month     . 

3 

At  two  months  . 

3^       " 

At  three  months 

4 

At  four  months 

4%        " 

At  five  months  . 

oM        " 

At  six  months 

6 

At  seven  months 

6%       " 

At  eight  months 

7M       " 

At  nine  months 

8M       " 

At  ten  months    . 

9 

At  eleven  months 

9M        '• 

At  twelve  months 

10 

30  CO. 
60  CO. 
90  CO. 

100  c.c. 
110  c.c. 
125  c.c. 
140  c.c. 
160  c.c. 
180  c.c. 
200  c.c. 
225  c.c. 
250  c.c. 
275  c.c. 
290  c.c. 


The  capacity  of  the  stomach,  of  course,  varies  normally  within 
considerable  limits.  The  capacity  of  the  infant's  stomach  at  different 
ages  is  best  obtained  by  estimating  the  average  amount  of  milk  in 


INTESTINE  45 

ounces  usually  taken  by  a  child  of  a  certain  age  or  size.  Children  of 
the  same  age  often  differ  greatly  in  size,  and  the  larger  the  child  the 
larger,  as  a  rule,  is  the  stomach.  In  deciding  upon  the  amount  of  food 
to  be  given  to  a  child  at  a  single  meal  it  must  be  remembered  that  a 
portion  of  the  food  taken  passes  out  of  the  stomach  during  the  swallow- 
ing of  the  meal,  and  that  the  tendency  of  the  stomach  is  to  empty 
itself  of  any  food  remaining  from  a  previous  meal  as  soon  as  the  food 
of  a  subsequent  meal  is  introduced,  the  rapidity  with  which  this  is 
accomplished  depending  largely  upon  the  composition  of  the  food  and 
its  amount.  If  a  milk  mixture  contains  a  high  percentage  of  fat,  it 
tends  to  pass  more  slowly  out  of  the  stomach  than  a  mixture  with  less 
fat  and  more  protein  and  sugar. 

In  the  young  breast-fed  infant  the  stomach  empties  itself  in  one 
and  one-half  to  two  hours,  this  depending  upon  the  size  of  the  meal. 
An  infant  fed  on  the  bottle  will  take  an  hour  longer  to  empty  its 
stomach  than  does  the  breast-fed  baby;  that  is,  two  and  one-half 
to  three  hours.  The  normal  reaction  of  the  stomach  at  birth  is  neutral 
or  acid,  but  is  always  acid  after  taking  either  breast  or  cows'  milk, 
owing  to  the  secretion  of  hydrochloric  acid.  This  is  present  one  and 
one-half  to  two  hours  after  a  meal  in  0.1  per  cent,  solution  in  healthy 
breast-fed  infants.  In  bottle  babies  free  hydrochloric  acid  may  not 
be  found,  owing  to  the  greater  ability  of  cows'  milk  to  combine  with 
acids.  The  contents  of  the  stomach  of  the  breast-fed  baby,  containing 
more  free  hydrochloric  acid,  are  therefore  more  antiseptic  than  in  the 
bottle-fed.  Lactic  acid  is  also  present  in  the  infant's  stomach  during 
digestion.  A  fat-splitting  ferment  is  also  found,  but  its  presence  is 
probably  of  comparatively  little  importance.  The  milk,  sugar,  and 
water  are  the  first  elements  of  the  food  to  pass  through  the  pylorus, 
and  are  followed  in  turn  by  the  albuminoids  and  the  fats.  Only  a  small 
amount  of  salts,  sugar,  and  protein  are  absorbed  from  the  stomach. 
Rennin  is  normally  present  in  the  stomach,  and  produces  coagulation 
of  the  casein,  the  hydrochloric  acid  dissolving  the  ciu-ds.  The  coagula 
of  cows'  milk  are  larger  and  firmer  than  those  of  human  milk,  and  are 
dissolved  with  more  difficulty  than  are  the  lighter  curds  of  human 
milk. 

Intestine. — The  length  of  the  intestine  in  the  newborn  is  about  seven 
to  twelve  feet  (200  to  400  cm.).  The  muscular  coat  is,  as  a  rule,  poorly 
developed,  in  the  infant,  whereas  the  solitary  follicles  and  Peyer's 
patches  are  relatively  better  developed.  According  to  Or  ban  and 
Weinland,  a  ferment  lactase  is  found  in  the ,  secretion  of  the  small 
bowel  capable  of  decomposing  lactose. 

The  pancreas  of  the  newborn  has  a  moderate  diastatic  action,  as 
well  as  a  distinct  fat  and  protein-splitting  function. 


CHAPTER  III. 
THE  CLINICAL  EXAMINATION  OF  SICK  CHILDREN. 

Ix  examining  an  ill  child,  it  is  absolutely  essential  never  to  hurry. 
It  may  be  necessary  to  coax,  amuse,  or  divert  an  infant;  but  the 
primary  idea  is  not  to  frighten  it,  and  the  presence  of  any  stranger  in 
the  room  is  often  sufficient  to  upset  the  delicate  nervous  organism  of 
an  infant  or  even  an  older  child.  The  early  portion  of  the  visit  should 
be  taken  up  by  questioning  the  mother  or  nurse,  first  carefully  eliciting 
the  family  history,  subsequently  the  personal  history  of  the  child, 
and  then  the  history  of  the  present  illness. 

Family  History.- — The  family  history  should  include  the  possibility 
of  syphilis,  tuberculosis,  alcoholism,  or  rheumatism;  the  number  of 
pregnancies;  the  number  of  children  living  and  in  health;  or,  if  sick, 
from  what  they  are  suffering;  the  number  of  children  dead  and  the 
causes  of  death.  The  hygienic  conditions  of  the  child's  previous, 
environment  should  be  inquired  into.  Has  it  been  an  open  air  or  a 
coddled  baby?  Has  it  been  recently  exposed  to  any  communicable 
disease?  At  what  age  was  the  first  tooth  cut,  and  how  many  teeth 
has  it  now?  When  did  the  child  creep,  stand  alone,  and  walk?  Was 
the  child  asphjrxiated  at  birth,  did  it  breathe  and  cry  immediately 
after  birth,  or  were  efforts  to  resuscitate  it  necessary  ?  How  long  was 
it  breast-fed,  wholly  or  in  part,  and  what  exactly  was  the  strength  of 
the  modified  milk  mixtures  or  other  food  given  it?  What  has  been 
its  diet  since  weaning?  If  any  records  of  the  child^s  weight  have  been 
kept,  they  should  be  carefully  studied. 

All  this  information  may  be  secured  in  a  few  minutes,  and  included 
in  the  child's  history  at  the  first  visit;  the  few  minutes  so  employed 
are  not  wasted;  once  obtained,  it  becomes  a  permanent  record,  and 
is  often  of  paramount  importance  in  establishing  a  past  or  present 
diagnosis.  Furthermore,  during  this  time  the  infant  or  older  child 
becomes  accustomed  to  the  physician's  presence. 

Inspection. — If  possible  the  child  should  always  be  examined  when 
asleep.  The  natural  instinct  of  the  mother  or  nurse  is  immediately  to 
arouse  the  child  upon  the  physician's  arrival.  ]Much  information  may, 
however,  be  secured  by  observing  the  child  while  he  is  asleep,  and 
by  studying  the  facial  expression,  which  may  indicate  a  quiet,  relaxed, 
nervous  system,  or  pain  and  tension.  The  child's  mental  powers  can 
be  gauged  and  compared  with  well-known  standards. 

Note  the  child's  general  development,  the  appearance  of  the  head, 
whether  hydrocephalic,  microcephalic,  or  asymmetrical.  Observe 
whether  there  is  a  bulging  or  sunken  condition  of  the  anterior 
fontanelle. 


PALPATION  47 

The  child's  color  should  be  noted;  cyanosis  may  suggest  congenital 
heart  disease;  puffiness  of  the  eyes  a  possible  acquired  endocarditis 
or  nephritis;  pallor  an  anemia,  probably  secondary.  Is  the  face 
pinched  and  toxic,  or  is  it  of  normal  contour  and  good  color?  Inspec- 
tion may  disclose  the  absence  or  presence  of  enlarged  glands  of  the 
neck.  It  may  also  show  any  abnormality  of  development  in  the  contour 
of  the  abdomen  and  chest.  A  bulging  in  the  precordia  may  suggest 
cardiac  hypertrophy,  or  a  systolic  dimpling  a  previous  pericarditis 
with  adhesions. 

The  development  of  the  upper  extremities  should  be  compared  with 
that  of  the  lower,  and  the  comparative  size  of  the  head  and  thorax 
noted.  The  eye  should  be  examined  as  to  the  presence  or  absence  of 
jaundice,  also  strabismus,  nystagmus,  or  ptosis.  The  pupils  are 
examined  as  to  their  size  and  their  reaction  to  light.  The  history 
should  include  the  presence  or  absence  of  pain,  discharge,  or  odor 
in  the  ears.  Many  cases  of  restlessness,  sleeplessness,  and  high  fever 
may  be  in  this  way  cleared  up.  Any  nasal  discharge  should  be  nqted. 
In  very  young  children  this  may  suggest  syphilis,  especially  if  it  be 
persistent  and  blood-tinged.  In  an  older  child  a  nasal  discharge  may 
mean  diphtheria;  or,  if  it  recurs  frec{uently,  possibly  adenoids.  If 
the  discharge  is  recent,  one-sided,  and  persistent  the  presence  of  a 
foreign  body  should  be  suspected. 

The  respiration  should  be  carefully  observed  as  to  whether  it  is 
rapid,  or  slow  and  irregular.  Pneumonia  may  be  suggested  by  the 
former  and  meningitis  by  the  latter.  Adenoids  will  be  thought  of  if 
the  child  is  a  mouth  breather,  or  if  it  snores.  If  there  is  cough  (and  in 
a  child  under  two  years  of  age  there  is,  of  course,  no  expectoration) 
a  specimen  of  sputum  may  be  obtained  by  passing  a  curved  probe 
wrapped  with  cotton  well  back  into  the  pharynx.  Rachitis  should  be 
looked  for  in  the  spine,  thorax,  and  extremities;  the  presence  or 
absence  of  spinal  or  joint  deformities  which  are  not  rachitic  may 
assist  in  forming  a  diagnosis  of  tuberculosis. 

The  posture  of  the  child  is  sometimes  significant.  Continual 
lying  on  one  side  is  suggestive  of  pleurisy  with  effusion.  Lying  im- 
movably on  the  back  with  the  legs  drawn  up  points  to  peritonitis. 
Sitting  up  in  bed  with  the  head  thrown  back  indicates  laryngeal 
obstruction.  An  eruption  or  desquamation  may  suggest  one  of  the 
exanthemata;  or,  if  desquamation  alone  exists,  recent  scarlet  fever 
or  syphilis.  Syphilis  may  also  be  indicated  by  disease  of  the  matrix 
resulting  in  suppuration  and  exfoliation  of  the  nail.  The  dorsum  is 
arched,  and  the  nail  appears  as  if  it  had  been  pinched  by  a  pair  of 
forceps,  i.  e.,  claw-shaped.  Inspiratory  dyspnea  is  shown  by  retraction 
of  the  suprasternal  notch,  the  supraclavicular  and  intercostal  spaces, 
and  retraction  of  the  abdomen.  It  should  be  noted  whether  the 
abdomen  is  distended  or  retracted.  Cyanosis  is  suggestive  of  congenital 
heart  disease,  especially  if  combined  with  clubbing  of  fingers  and  toes. 

Palpation. — Palpation  should  always  precede  percussion,  and  usually 
precedes  auscultation.     The  anterior  fontanelle  shoukl  be  palpated. 


48  CLINICAL  EXAMINATION  OF  SICK  CHILDREN 

Is  it  large  or  small  for  the  age  of  the  child,  and  does  it  bulge  or  is  it 
teDse?  Are  the  cranial  sutures  open  or  closed?  In  early  infancy,  if 
the  child  is  emaciated  and  marasmic,  the  posterior  portion  of  the  head 
may  show  the  presence  of  craniotabes  (thinning  of  the  infantile  skull 
in  spots)  which  suggests  rickets  or  lues. 

Palpation  may  reveal  the  presence  or  absence  of  enlarged  glands 
of  the  neck,  or  change  in  the  size  of  the  thyroid.  An  increase  in  tactile 
fremitus  would  suggest  lung  consolidation,  pneumonic  or  tuberculous, 
while  a  decrease  might  indicate  pleural  effusion.  Palpation  may  dis- 
close the  existence  of  a  cardiac  thrill  or  murmur,  and  an  enlarged 
or  displaced  heart  can  be  diagnosed  by  displacement  of  the  apex  beat. 
The  apex  beat  in  the  newborn  infant  may  be  felt  higher  than  in  the 
adult,  this  being  partly  due  to  the  higher  position  of  the  diaphragm. 
On  account  of  the  greater  breadth  of  the  heart  as  compared  with  that 
of  the  chest,  the  apex  is  external  to  the  mammary  line,  and  remains 
so  until  the  fourth  year,  and  from  this  time  to  the  ninth  year  it  is  in  or 
nea^  the  mammary  line.  During  the  first  year  the  apex  beat  is  found 
in  the  fourth  and,  subsequently,  as  a  rule,  in  the  fifth  intercostal  space. 
A  feeble  apex  beat  does  not  in  itself  prove  anything;  it  is  sometimes 
hardly  perceptible,  even  in  healthy  children,  but  the  case  is  entirely 
different  if  it  becomes  weak  or  disappears  during  the  course  of  some 
disease,  when  it  indicates  either  imminent  heart  failure  or  the  formation 
of  pericardial  exudation. 

The  normal  liver  extends  about  one  inch  below  the  free  border  of 
the  ribs,  and  if  it  is  enlarged  the  increase  in  size  may  be  disclosed  by 
palpation.  The  spleen,  if  of  normal  size,  is  not  palpable;  hence,  if 
demonstrable  by  palpation  it  must  be  enlarged.  Bimanual  palpation 
of  the  abdomen,  the  child  lying  on  its  back  with  the  knees  flexed, 
may  enable  one  to  recognize  foreign  masses  in  the  abdomen;  or, 
better  results  can  sometimes  be  secured  by  digital  examination  per 
rectum.  Bimanual  examination  with  the  finger  in  the  rectum  is  often 
of  advantage.  By  this  method  we  may  detect  abdominal  growths, 
enlarged  glands,  or  a  calculus. 

Dropsy  in  the  face,  abdomen,  or  extremities  may  be  determined  by 
palpation.  Kernig's  sign,  i.  e.,  inability  to  extend  the  lower  leg  if  the 
thigh  is  flexed  on  the  abdomen,  and  Babinski's  reflex,  i.  e.,  extension 
of  the  great  toe  with  spreading  of  the  adjacent  toes  upon  stroking  the 
sole  of  the  foot  from  the  heel  to  the  toes,  preferably  on  the  inner  side, 
with  a  moderately  sharp  instrument  such  as  a  toothpick,  may  be  of 
more  or  less  assistance  in  confirming  a  diagnosis.  It  must  be  noted 
that  the  Babinski  reflex  is  of  value  only  in  children  over  one  year 
of  age. 

Auscultation. — Auscultation  in  the  child  should,  as  a  rule,  follow 
palpation.  Sometimes,  however,  it  will  be  advisable  to  perform 
auscultation  before  palpation.  Some  children  may  be  more  willing 
to  submit  to  the  former  than  to  the  latter.  It  is  well  to  auscultate 
the  posterior  surface  of  the  chest  first,  and  to  use  a  stethoscope  with  a 
small  bell  when  auscultating  the  axillae. 


MENSURATION  49 

Percussion. — Percussion  follows  auscultation.  It  should  always  be 
performed  gently,  the  posterior  aspect  before  the  anterior.  On  com- 
paring the  two  sides  of  the  chest,  the  area  of  relative  cardiac  dulness 
and  the  area  of  absolute  cardiac  dulness  in  the  infant  and  older  child 
may  be  mapped  out.  The  area  of  relative  cardiac  dulness  is  at  the 
upper  boundary  of  the  second  interspace,  or  the  lower  border  of  the 
second  costal  cartilage,  at  the  left  margin  of  the  sternum.  From  this 
point  the  line  of  dulness  extends  in  a  curved  direction  outward  and 
downward,  the  extreme  left  limit  being  at  or  slightly  beyond  the  mam- 
mary line  in  the  fourth  interspace.  On  the  right  side,  the  line  of  dulness 
extends  downward  from  the  second  interspace  in  a  slightly  curved 
dhection  along  the  parasternal  line.  The  lower  border  is  undetermin- 
able on  account  of  the  liver. 

The  area  of  absolute  or  superficial  cardiac  dulness  is  that  part  of  the 
heart  not*  covered  by  the  lung,  resembling  in  shape  the  same  area  as 
in  the  adult,  but  being  relatively  longer.  Its  upper  limit  is  the  upper 
border  of  the  third  intercostal  space,  sometimes  the  third  costal 
cartilage;  it  extends  to  the  left  to  a  point  between  the  parasternal 
and  the  ^lammary  lines,  and  to  the  right  as  far  as  the  left  border  of  the 
sternum. 

Percussion  enables  one  to  detect  the  presence  of  fluid  in  the  abdo- 
men, and  auscultatory  percussion  (percussing  in  the  ordinary  manner 
and  listening  over  this  area  with  a  stethoscope)  is  often  of  advantage 
in  pulmonary,  cardiac,  and  abdominal  conditions. 

Mensuration. — Mensuration  enables  one  to  compare  the  size  of  the 
head,  thorax,  and  abdomen,  although  it  must  be  remembered  that 
temporary  conditions  often  produce  marked  variations  in  abdominal 
measurements.  The  circumference  of  the  head  in  comparison  with 
that  of  the  thorax,  from  birth  up  to  fifteen  years  of  age,  has  been 
tabulated  on  page  34. 

The  length  of  the  child  is  of  importance.  Infants  and  younger 
children  are  best  measured  by  placing  them  in  the  recumbent  posture, 
with  a  card  or  book  vertically  at  the  head  and  feet,  then  measuring 
the  intervening  space.  For  older  children  a  measuring  rod  placed 
against  the  wall  or  the  ordinary  measuring  rod  that  is  attached  to 
weight  scales  may  be  employed. 

The  cry  of  the  child  may  be  of  more  or  less  assistance  in  locating 
the  seat  of  the  disease;  the  cry  of  pain  may  be  sharp,  acute,  and 
accompanied  by  some  attempt  at  localization,  with  contraction  of  the 
features;  whereas  young  infants  may  be  only  restless  and  irritable. 
The  cry  of  fright,  as  when  a  stranger  enters  the  room,  begins  when  such 
a  person  arrives  and  ceases  when  he  leaves.  The  cry  of  pneumonia 
is  short  and  catchy,  i.  e.,  an  expiratory  grunt;  that  in  laryngitis  is 
croupy;  in  extreme  exhaustion  or  marasmus  we  hear  only  a  feeble 
whine.  A  moaning  cry  suggests  intestinal  disease.  In  scurvy  the 
child's  cry  is  sharp,  and  occurs  especially  when  it  is  touched. 


CHAPTER  IV. 
INFANT  MORTALITY. 

The  modern  tendency  in  medicine  is  to  concentrate  each  individual's 
efforts  within  comparatively  narrow  Hmits;  if  possible,  to  add  some 
new  facts  or  theories  to  present  knowledge.  The  sum  total  of  all  the 
additions  and  advances  has  revolutionized  medical  knowledge  in 
the  last  twenty  years.  Countless  intelligent  and  zealous  physicians 
working  along  different  lines  and  in  special  departments  of  medicine 
have  made  it  difficult,  if  not  impossible,  for  any  one  to  keep  fully 
abreast  of  the  times  in  all  branches  of  medical  science. 

Perhaps  this  tendency  in  modern  medical  study  has  led  to  the 
neglect  of  certain  broad  principles  of  hygiene,  diet,  fresh  air,  bathing 
and  general  methods  of  living;  these,  being  every  one's  business, 
have  become  no  one's  business. 

John  Gardner,  surgeon,  London,  wrote  in  1838  an  interesting 
pamphlet  on  "Why  So  Large  a  Number  of  Children  Perish."  He 
appreciated  certain  physiological  differences  between  a  child  and  an 
adult,  and  under  "Dentition"  wrote: 

The  true  nature  of  the  effect  of  this  natural  process  on  the  health 
and  life  of  children  is  much  misapprehended.  In  a  healthy  body, 
the  teeth  are  always  cut  without  suffering,  and  not  far  wide  of  the 
ninth  month.  The  passage  of  the  teeth  through  the  gums  produces  a 
slight  excitement,  which  is  not  a  deviation  from  health. 

Benjamin  J.  Crew,  of  Philadelphia,  wrote  in  1882  an  excellent  article 
on  "The  Care  of  Deserted  Infants,"  which  was  read  before  the  assembly 
meeting  of  the  Philadelphia  Society  for  Organizing  Charity  in  March 
of  that  year.  In  this  article  he  strongly  advocates  a  combination  of 
"  placing  out"  and  "  asylum  plan"  for  these  infants,  and  quotes  statistics 
which  clearly  prove  how  great  is  the  reduction  in  the  mortality  in 
infants  under  the  plan  of  treatment  advocated. 

J.  Brendon  Curgenven,  M.R.C.S.,  London,  1867,  writing  on  "The 
Waste  of  Infant  Life,"  states  that  the  excess  of  infantile  mortality 
occurs  in  laboring  people.  The  poorer  and  lower  classes  show  a 
mortality  of  35  to  55  per  cent,  under  the  age  of  five  years;  the  educated 
and  well-to-do,  only  1 1  per  cent.  He  analyzes  the  Registrar  General's 
report,  and  shows  clearly  the  causes  of  this  excess  of  24  to  44  per  cent, 
of  deaths.    Reference  will  be  made  to  these  statistics  later. 

In  an  article  written  by  Dr.  William  Farr,  over  thirty  years  ago, 
he  stated  that  the  mean  annual  death  rate  of  infants  under  one  year 
in  some  of  the  principal  countries  of  Europe  was  as  follows:  Out  of 
one  thousand  infants  there  died  yearly  in  Sweden  141.8;  in  Denmark, 
137.5;  in  England,  182.6;  in  France,  223.2;  in  the  Netherlands,  237.5; 
in  Spain,  249.6;  in  Italy,  273.3. 


GENERAL  STATISTICS  51 

The  annual  death  rate  in  one  thousand  children  under  five  years, 
according  to  the  same  authority,  was:  In  Norway,  40.9;  in  Sweden, 
51.4;  in  Denmark,  52.7;  in  England,  67.6;  in  Belgium,  74.9;  in 
France,  79.2;  in  Prussia,  82.4;  in  Holland,  91.2;  in  Austria,  104.0; 
in  Spain,  111.7;  in  Italy,  113.5.  The  United  States  census  for  1910 
shows  that  265,000  babies  died  during  their  first  year  and  53,000 
in  their  second  year. 

A.  Brothers,  B.S.,  M,D.,  in  1896,  in  his  article  on  "Infantile  IMortality 
during  Child-birth  and  its  Prevention,"  states  that  in  the  four  years, 
1889  to  1892,  the  total  number  of  births  in  New  York  City  was  173, 126, 
and  that  during  this  period  of  four  years  16,888  children  born  at  term 
had  died  within  the  age  of  one  month.  Ten  per  cent,  of  the  children, 
therefore,  are  lost  before  they  reach  the  age  of  one  month. 

Collective  statistics  from  sixteen  European  cities  embracing  1,439,056 
children  show  that  10  per  cent,  of  those  born  alive  die  within  the  first 
four  weeks  of  life.  Eross'  statistics  show  that  the  greatest  number  of 
deaths  occurred  on  the  first  day  of  life,  and  that  the  deaths  diminish 
day  by  day.  According  to  Eross,  54.24  per  cent,  of  the  deaths  among 
children  within  four  weeks  after  birth  are  due  to  congenital  debility. 

Dr.  Shaw,  in  the  Albany  Medical  Journal,  1913,  states  that  in  the 
United  States  300,000  babies  die  annually  before  they  reach  the  age 
of  twelve  months.  The  ratio  of  infant  mortality  to  births  is  150 
to  1000;  in  other  words,  one  baby  in  seven  dies  before  it  is  one  year 
old. 

In  New  York  State  the  death  rate  in  these  infants  is  121  to  1000; 
in  Vermont,  145  to  1000;  in  Burlington,  Vt.,  it  is  230  to  1000;  in 
London,  England,  90  to  1000;  in  Great  Britain,  130  to  1000;  in  New- 
Zealand,  62  to  1000;  in  Chili,  331  to  1000;  and  in  Russia,  240  to  1000. 

Phelps  states  that  in  England  and  Wales,  in  1912,  the  death  rate 
in  infants  born  alive  was  95  to  1000. 

William  Moore,  in  a  paper  read  before  the  Dublin  Obstetrical 
Society  in  1859,  states  that  the  proportion  of  deaths  throughout 
England,  under  all  ordinary  conditions  of  life,  is  believed  to  be  one  in 
six  within  the  first  year.  To  parallel  this  proportion  of  mortality,  we 
must  pass  on  to  those  dying  between  the  ages  of  80  and  85. 

Dr.  D.  Meredith  Reese,  of  New  York,  reported  at  the  meeting  of 
the  American  Medical  Association  in  May,  1857,  that  nearly  50  per 
cent,  of  the  total  deaths  in  large  cities  occurred  in  children  under  five 
years  of  age.  In  New  York  City  in  the  fifty  years,  1804  to  1853,  the 
whole  mortality  was  363,242,  including  stillbirths,  and  during  this 
period  176,043  children  under  the  age  of  five  years  died — nearly  49 
per  cent,  of  the  entire  number  of  deaths. 

M.  Bertillon  stated  before  the  Academy  of  Medicine  of  Paris  that 
in  a  period  of  ten  years  there  had  been  in  France  9,700,000  births; 
of  those  born  1,500,000  died  within  the  first  year  of  life. 

Morse  makes  the  statement  that  85  per  cent,  of  all  infants  who 
die  are  bottle-fed  babies,  and  that  90  per  cent,  of  all  deaths  due  to 
diarrheal  conditions  occur  in  those  who  are  bottle-fed. 


52  INFANT  MORTALITY 

J.  ]Maiile  Sutton,  ]\I.D.,  of  London,  in  1872,  drew  attention  to  the 
influence  exerted  on  infant  mortality  by  the  social  status  of  the  parents. 
His  figures  give  a  mortality  of  77  per  thousand  for  children  under  one 
year  of  age  in  urban  population;  and  a  lower  percentage  for  rural 
population.  These  same  districts,  excluding  the  upper-class  births, 
gave  a  mortality  of  158  per  thousand.  He  studied  the  infant  mortality 
among  the  children  of  the  farmers  of  Devonshire  and  Norfolk,  two 
agricultural  counties,  and  found  it  to  be  95  per  thousand  in  the 
farming  class;  the  rate  among  the  children  whose  parents  were  not 
farmers  was  130  per  thousand. 

John  S.  Parry,  M.D.,  of  Philadelphia,  in  1871,  quotes  Dr.  A.  Jacobi 
as  saying  that  "of  100  infants  born  alive  to  the  gentry  of  England 
(1844)  there  died  20;  to  the  working  classes,  50.  In  the  aristocratic 
families  of  Germany  there  died  in  four  years  5.7  per  cent.;  among 
the  poor  of  Berlin,  34.5  per  cent.  In  Brussels  the  mortality,  up  to  the 
fifth  year,  was  6  per  cent,  in  the  families  of  capitalists,  33  among 
tradesmen  and  professional  people,  and  54  among  workingmen  and 
domestics."  Quoting  de  Villiers,  he  further  writes  that  "the  mortality 
among  the  children  of  the  workingmen  of  Lyons  is  35  per  cent.,  and 
in  well-to-do  families  and  agricultural  districts  it  is  10  per  cent." 

Dr.  George  Reid,  in  1906,  in  London,  at  the  National  Conference  on 
Infant  Mortality,  in  considering  social  status  as  an  etiologic  factor, 
divides  the  working  class  into  three  groups:  (1)  Those  among  whom 
the  proportion  of  employed,  married  and  widowed  females  between 
eighteen  and  fifty  years  of  age  reached  or  exceeded  12  per  cent.; 
(2)  those  among  whom  the  proportion  was  6  to  12  per  cent.;  (3)  those 
among  whom  the  proportion  was  below  6  per  cent.  The  decades,  1881 
to  1890,  1891  to  1900,  and  the  four  years,  1901  to  1904,  were  studied. 
The  infant  mortality  was  always  highest  in  group  1  and  lowest  in 
group  3.  The  average  yearly  infant  mortality  rates  of  group  1  were 
195,  212  and  193;  group  2,''l65,  175,  156;  group  3,  156,  168,  149. 
These  statistics  point  out  in  no  uncertain  manner  the  fact  that  the 
infants  of  women  employed  in  industrial  and  manufacturing  plants 
during  the  time  of  their  married  life  and  motherhood  are  born  into  this 
world  with  less  chance  of  battling  with  the  problem  of  living  than 
those  whose  mothers  are  not  compelled  to  perform  this  kind  of  work. 
The  wives  of  farmers  may  and  often  do  perform  hard  work,  but  it  is 
done  more  or  less  out  of  doors,  and  not  in  the  vitiated  and  contaminated 
atmosphere  of  a  mill  or  factory. 

Helle  examined  into  the  social  status  of  the  parents  of  170  infants 
dying  in  Graz  during  1903  and  1904;  112  infants  who  died  had  very 
poor  parents;  49  children  had  poor  parents;  9  had  well-to-do  parents, 
and  no  deaths  occurred  among  the  children  of  the  rich ;  the  percentage 
of  the  four  classes  being  65.9,  28.8,  5.3,  0.  The  general  infant  mortality 
in  Graz  has  markedly  decreased  in  the  last  twenty  years,  while  the 
mortality  due  to  gastro-intestinal  lesions  does  not  show  any  marked 
diminution. 

In  Briin,  a  city  of  110,000  inhabitants,  the  health  statistics  for 
fifteen  years  show  that  the  general  infant  mortality  during  this  time 


GENERAL  STATISTICS  o3 

decreased  very  niiicli,  Avliile  that  due  to  gastro-intestitial  lesion^ 
changed  very  httle. 

In  Berhn,  1903,  Newman  mvestigated  2701  infant  deaths.  Where 
the  famiHes  were  m  one-room  dweUings  he  found  1792  deaths;  m  two- 
room  dwellings,  754  deaths;  in  three-room  dwellings,  122  deaths,  and 
in  larger  dwelHngs,  43  deaths.  It  seems  to  be  an  estabhshed  fact  that 
the  percentage  of  deaths  among  infants  of  the  poor  largely  exceeds 
the  mortality  among  the  infants  of  the  rich. 

The  hygienic  siu-roundings  of  the  infant — city  or  country  life — 
are  factors  which  play  an  important  part  in  the  sum  total  of  infant 
mortality.  In  England  and  Wales,  77  per  cent,  of  the  whole  population 
is  urban;  fifty  years  ago  the  population  w^as  equally  divided  between 
urban  and  rural  districts.  A  considerable  portion  of  this  urban  popu- 
lation lives  in  small  towns,  more  closely  resembling  country  than  city 
life.  In  the  year  1904,  in  England  and  Wales,  59.1  per  cent,  of  the 
people  lived  in  large  towns  of  over  20,000  inhabitants;  in  1801,  only 
16.7  per  cent,  lived  in  large  towns. 

It  seems  clear  to  me  that  this  tendency  to  live  more  in  large  to\\Tis 
has  much  to  do  w4th  the  stationary  infant  mortality  in  England  and 
Wales.  City  life  means  for  the  parents,  often,  long  hours  of  work  in 
a  factory  or  mill;  living  in  a  small  house  in  a  small  street,  often  poor 
food,  and  not  uncommonly  dissipation  of  drink  and  perhaps  immorality. 

Epidemic  diarrhea  is  mostly  a  disease  of  large  towns  and  cities. 
It  can  be  positively  stated  that  geological  strata,  character  of  soil  and 
climate  have  nothing  to  do  wdth  infant  mortality,  nor  is  it  entirely 
a  question  of  poverty.  Overwork,  poor  hygienic  surroundings,  and 
poor  housing  seem  to  be  two  powerful  factors  causing  infant  deaths. 
Densit}^  of  population  jper  se  may  and  does  mean  a  good  deal  in  causing 
deaths  in  infants.  Urban  England  has  a  higher  infant  mortality  than 
rural  England.  However,  in  first-class  modern  houses,  the  popu- 
lation may  in  a  given  area  be  dense,  but  the  infant  death  rate  may  be 
small  if  other  factors  are  present,  as  good  hygiene,  food,  fresh  air, 
healthful  occupations  and  good  social  status. 

If  a  town  is  distinctly  industrial  or  manufacturing,  the  mortality 
invariably  exceeds  that  of  the  town  where  the  occupations  have  more 
of  an  agricultural  tendency.  Table  1,  by  Newman,  shows  the  infant 
mortality  in  the  country  of  Wiltshire,  in  which  there  are  no  large  towns; 
it  shows  also  that  even  under  favorable  conditions  the  city  mortality 
exceeds  the  rural  mortality;  it  also  shows  the  high  mortality  of  large 
towns,  and  the  mortality  of  England  and  Wales,  and  rural  England 
and  Whales. 

Table  1. — Infant  Mortality  Rates  in  Wiltshire  and  Englantj  and  Wales, 

1900-1904. 


Districts. 

1900. 

1901. 

1902. 

1903. 

1904. 

County  of  Wiltshire    . 

94.0 

93.7 

97.23 

85.63 

95.99 

Urban  districts  (Wilts.) 

95.6 

106.8 

93.63 

89.27 

100.32 

Rural  districts  (Wilts.) 

115.7 

83.8 

99.89 

82.76 

92.52 

England  and  Wales 

154.0 

151.0 

133.0 

132.0 

145.0 

Large  towns  in  England 

172.0 

168.0 

145.0 

144.0 

160.0 

Rural  England  and  Wale. 

3      138.0 

137 . 0 

135.0 

118.0 

125.0 

54  INFANT  MORTALITY 

In  these  two  countries  the  higliest  infant  mortahty  occurs  in  large 
towns;  next,  in  large  towns  and  rural  districts;  and  the  lowest  mor- 
tality in  rural  districts. 

Table  2,  by  Newsman,  shows  the  remarkable  difference  in  infant 
mortality  in  three  agricultural  counties,  five  mining  and  manufacturing 
counties,  and  three  towns  where  textile  industries  and  mining  are 
largely  followed. 


TABLE 

2. 

Of  100,000  infants  born,  the  number         Annual  death  rates 

per  1,000  living 

surviving 

:  at  each  age. 

in 

each  successive 

interval  of 

age. 

2.     r 

mining    and 
ufacturing 
ties:    Staffs., 
,Lanos.,W.R. 
:s,  Durham. 

selected 
s:     Preston, 
kburn,     Lei- 
r. 

§  . 

u  ax 

a 

'a 

'b 

a  to 

o 
o 

(D  m-S 

C  C  o-T 

O   Bo   <D 

a 

c 

s  <»•? 

J>  03  3-g  o 

S   ^^^ 

o  3 

<p  3 

„ 

g-^ 

-S  g 

j3 
Eh 

100,000 

100,000 

100,000 

213 

331 

382 

Age. 


At  birth  . 

3  months  .  .  .  94,820  92,051  90,874               75             154             240 

6  months  .  .  .  93,068  88,574  85,574               61             128             180 

12  months  .  .  .  90,283  83,081  78,197 

This  table  covers  the  three  years,  1889  to  1891,  and  shows  that  of 
100,000  infants  born  in  the  rural  counties  10,000  died;  in  the  manu- 
facturing counties  17,000  died,  and  in  the  manufacturing  towns,  22,000. 
An  important  point  to  notice  in  this  table  is  that  the  town  rates  are 
most  in  excess  of  the  rural  rates  in  the  later  months  of  the  first  year 
of  life,  showing  clearly  that  the  congenital  conditions,  atrophy  and 
immaturity,  can  be  left  out  of  consideration,  and  that  the  continuous 
ill  effect  of  town  life  finally  kills  many  children  that  have  made  -a  strong 
but  useless  struggle  against  their  environment.  Epidemic  diarrhea 
plays  a  powerful  part  in  this  sacrifice  of  infant  iife  in  those  towns 
where  textile  industries,  manufacturing  and  mining,  flourish. 

The  deaths  occurring  during  the  first  year  of  life  are  very  unevenly 
distributed.  This  applies  to  all  countries,  and  all  statistics  that  I 
have  been  able  to  find  prove  it  absolutely.  The  greatest  percentage 
of  deaths  occurs  in  the  first  three  months  of  life,  and  I  believe  that  this 
percentage  is  increasing  and  not  decreasing.  In  London  during  the 
years  1839  to  1844,  24,354  infants  died  during  the  first  three  months 
of  life,  an  infant  death  rate  of  68  per  thousand.  In  the  same  city  in 
the  years  1898  to  1903,  56,963  infants  died  during  the  first  three  months 
of  life,  a  death  rate  of  72  per  thousand.  According  to  Newman, 
there  has  been,  in  recent  years,  an  increased  percentage  of  infant 
deaths  in  England  and  Wales  during  the  first  three  months,  and  a 
slight  decrease  in  the  percentage  of  deaths  during  the  last  six  months 
of  the  first  year.  Newman  asserts  that  infants  die  more  from  im- 
maturity at  the  present  time,  and  that  consequently  more  infants 
begin  life  with  less  vitality  than  in  former  periods.  He  also  states: 
"  Children  under  twelve  months  of  age  die  in  England  today,  in  spite 
of  all  our  boasted  progress  and  in  spite  of  an  immense  improvement  in 


GENERAL  STATISTICS  55 

tlie  social  and  ph}'sical  life  of  the  people,  as  greatly  as  they  did  seventy 
years  ago." 

The  report  of  the  Registrar  General  of  England,  for  1903,  shows 
for  England  and  Wales,  51.4  per  cent,  of  infant  deaths  in  the  first  three 
months;  19.9  per  cent,  in  the  second  three  months,  and  28.7  per  cent, 
in  the  last  six  months  of  the  first  year  of  life.  In  the  year  1904,  in 
Berlin,  53.6  per  cent,  of  deaths  of  infants  under  one  year  occurred  in 
the  first  three  months.  These  deaths  are,  of  course,  distributed  over 
the  entire  calendar  year,  and  this  observation  consequently  is  not 
contradicted  by  the  fact  that  the  greatest  number  of  deaths  was  in 
the  hot  months.  Births  occur  in  each  month  with  fair  regularity,  and 
the  congenital  conditions  which  contribute  so  largely  to  this  mortality 
in  the  first  few  weeks  of  infant  existence  are  consequently  distributed 
with  fair  regularity  throughout  the  year. 

Morse  classifies  the  causes  of  infantile  mortality  as  follows : 

Per  cent. 
Prematiirity,  congenital  debility,  congenital  defects,  accidents  at  birth  25 

Acute  gastro-intestinal  diseases       .      • ^^HO 

Diseases  of  nutrition 15/ 

Acute  respiratory  diseases / 25 

Acute  infectious  diseases 3 

Tuberculosis 2 

Syphilis •  1 

Unclassified 9 

The  following  table  shows  the  causes  of  infant  mortality  in  Phila- 
delphia during  the  year  1915: 

Disease.  Under      One  to  two 

one  year.        years. 

General  diseases 118  195 

General  diseases,  non-epidemic 181  82 

Diseases  of  the  nervous  system 113  17 

Diseases  of  the  circulatory  system 27  8 

Diseases  of  the  respiratory  system  (pneumonia  excepted)        ...  145  45 

Pneumonia,  all  forms 598  293 

Diseases  of  the  digestive  system  (diarrhea  and  enteritis  excepted)     .  124  32 

Diarrhea  and  enteritis 1168  213 

Skin  diseases 34  1 

Diseases  of  the  genito-urinary  system 10  7 

Diseases  of  the  locomotor  .system 2  2 

Malformation  and  early  infancy 1560  9 

Violence 40  25 

Injuries  at  birth 99  ... 

Ill-definod 1  S 

Totals 4220  937 

During  the  year  1914  there  were  41,063  births  reported  in 
Philadelphia  and  1929  stillbirths  registered  as  deaths.  The  causes 
of  infant  mortality  in  Philadelphia  for  the  year  1914  were  as  follows: 


56  INFANT  MORTALITY 

INFANT    MORTALITY— AGE   PERIODS    UNDER    ONE    YEAR. 

rndcr  1      1  week  to       1  to  3  3  to  0        0  to  12 

Diseases.  Total.  week.        1  month,    months,     months,    months. 

Total 4981  1125  750  839  930  1337 

General  diseases,  epidemic     .      .  208  2  12  30  41  123 

General  diseases,  non-epidemic    .  179  16  25  30  47  61 

Diseases  of  nervous  system    .       .  81  20  11  15  20  15 

Diseases  of  circulatory  system     .10  3  1  4  .  .  .  2 
Diseases  of    respiratory    sj'stem 

(pneumonia  excepted)  .  .  .  220  11  35  45  55  74 
Pneumonia,  all  forms  .  .  733  19  80  150  173  311 
Diseases  of  digestive  system  (di- 
arrhea and  enteritis  excepted)  138  6  12  22  32  66 
Diarrhea  and  enteritis  .  .  .  1474  14  143  303  442  572 
Diseases  of  genito-urinary  system  14  2,3  6  1  2 

Skin  diseases 32           10  10  1  11 

Diseases  of  locomotor  system      .  3  ....  ...  1  ...  2 

Malformation  and  early  infancy  1736  946  395  206  106  83 

Violence 50  6  5  12  12  15 

Injuries  at  Ijirth 101  80  16  5  ...             

Ill-defined 2           2  ...  ...            

Living  at  birth 41,063 

Stillbirths  registered  as  deaths 1,929 

The  added  deaths  from  gastro -intestinal  disease,  occurring  as  they 
do  in  great  excess  in  the  hot  months,  cause  the  great  increase  in  the 
total  infant  mortality  for  the  heated  term. 

Schereschewsky  gives  us  the  following  figures  to  show  the  effect  of 
heat  on  infant  mortality: 

The  number  of  deaths  in  Berlin  in  Jul}^  and  August  of  1910  (a  cool 
summer)  was  1439,  while  in  July  and  August  of  1911,  which  was  a 
very  hot  summer,  2050  infants  died.  The  universally  hot  summer  of 
1911  in  Europe  caused  a  clearly  demonstrable  rise  in  the  number  of 
deaths  in  infants  in  every  locality  where  statistics  were  compared. 

The  following  table  of  deaths  from  diarrhea  and  enteritis  shows  the 
increase  in  infantile  mortality  during  the  summer  months  of  1914  in 
Philadelphia : 

MORTALITY  IN  INFANTS  UNDER  ONE  YEAR  OF  AGE. 


Jan. 

Feb. 

Mar. 

Apr. 

May. 

June. 

July. 

Aug. 

Sept. 

Oct. 

Nov. 

Dec. 

Breast-fed   . 

8 

9 

13 

9 

10 

7 

8 

28 

22 

18 

11 

10 

Artificially  fed 

21 

14 

15 

13 

16 

4 

155 

148 

104 

56 

36 

24 

No  data   as   to 

feeding     . 

9 

18 

21 

17 

27 

50 

138 

161 

71 

73 

30 

34 

Totals 

38 

41 

49 

39 

53 

61 

301 

337 

197 

147 

83 

68 

The  outside  and  home  emploj'ment  of  mothers  is  a  factor  in  infant 
mortality  that  was  appreciated  long  since,  and  led  Sir  John  Simon  in 
1856  to  .state  that  "infants  perish  under  the  neglect  and  mismanage- 
ment which  their  mothers'  occupation  implies."  In  Dundee  a  large 
percentage  of  the  female  population  of  girls  and  married  women 
work  in  the  jute  and  hemp  factories.  The  labor  is  unskilled,  the  wages 
small  and  the  hours  6  a.m.  to  6  p.m.  These  women  and  girls  are,  as  a 
class,  subnormal  in  Aveight  and  general  physical  development;  many 


GENERAL  STATISTICS  57 

of  tlie  children  are  Ijorii  and  raised  in  houses  containing  only  one  or 
two  njoms,  or  in  large  tenements,  where  overcrowding  and,  usually, 
uncleanliness  exist.  In  the  ten  years,  1893  to  1902,  the  infant  mortality 
was  176  per  thousand  births;  in  1904,  out  of  174  deaths,  125  were  due 
to  prematurity  and  immaturity,  and  over  49  per  cent,  of  the  deaths 
occurred  in  the  first  three  months  of  life. 

In  England  the  Factory  Act  of  1901  states :  "  An  occupier  of  a  factory 
or  workshop  shall  not  knowingly  allow  a  woman  or  girl  to  be  emplo>-ed 
therein  within  four  weeks  after  she  has  given  birth  to  a  child."  This 
is  positive  legislation  of  a  far-reaching  character.  If  the  hygienic 
conditions  of  air,  light  and  cleanliness  were  only  adequately  controlled 
by  law^  in  these  mills  or  factories,  and  such  provisions  for  sanitary 
surroundings  as  are  needful  were  insisted  on,  much  could  be  done  to 
remove  the  injurious  influences  of  this  class  of  employment.  Much 
has  already  been  accomplished  in  this  direction,  but  much  still  remains 
to  be  done. 

In  Kearsley,  a  town  of  Lancashire,  of  9500  population,  the  infant 
death  rate  increased  from  179  per  thousand  in  1894-1903  to  192  in 
1903,  and  229  in  1904;  and  this  is  due,  according  to  J.  C.  Eames,  M.D., 
medical  officer  of  the  town,  to  the  town  having  "  developed  into  more 
of   a   manufacturing   district." 

In  Mulhouse,  Mr.  Dollfus,  who  owned  a  large  cotton  mill,  established 
a  fund  to  which  all  the  married  women  subscribed,  and  he  personally 
contributed.  Each  woman  subscribing  received  from  the  fund  sufficient 
for  her  support  during  the  two  months  following  her  confinement. 
On  resuming  work  at  the  end  of  this  two  months,  she  was  granted  time 
at  midday  to  return  home  and  care  for  her  baby.  This  procedure 
alone  reduced  the  infant  mortality  more  than  50  per  cent. 

In  1876  there  was  established  in  England  a  Society  for  Nursing 
Mothers.  The  object  of  the  Society  is  to  save  the  child's  life  by 
preserving  the  health  of  the  mother.  The  mothers  are  cared  for  in 
institutions  for  several  weeks  before  confinement,  being  well  fed  and 
housed;  but,  what  is  more  important  is  that,  diu"ing  the  first  year  of 
the  child's  life,  the  mother  is  cared  for  wholly  or  in  part,  as  it  is  neces- 
sary. A  physician  and  nurse  visit  her  at  her  house  and  give  her 
the  assistance  she  may  require.  Each  month  the  child  is  weighed, 
thoroughly  examined,  and  if  sick  is  always  taken  care  of.  The  Society 
has  cared  for  over  forty  thousand  children,  and  the  saving  of  infant 
life  has  been  very  great. 

In  Paris  since  1904  the  Coullet  dining-rooms  have  gone  one  step 
ahead  of  anything  done,  as  far  as  I  know,  in  America.  They  have 
established  restaurants  in  the  poorer  districts  of  Paris;  any  woman  w^ho 
is  nursing  a  baby  is  given  free  of  all  cost  two  good  meals  each  day. 
They  feed  the  mother,  and  the  mother  nurses  the  baby. 

Since  all  empires  are  built  of  babies,  unless  a  change  in  the  trend  of 
statistics  of  infant  mortality  shall  take  place,  our  future  generations 
will  fail  to  develop  physically  and  numerically  along  the  lines  which 
are  both  normal  and  natural.    Race  suicide  is  not  a  theorv,  but  a  fact. 


58  INFANT  MORTALITY 

France  is  actually  facing  slow  extinction;  its  birth  rate  is  smaller  than 
that  of  any  other  European  nation.  The  trouble  and  expense  incident 
to  the  care  and  rearing  of  children  does  not  appeal  to  all  women  of  the 
present  day;  motherhood  is  not  always  synonymous  with  wifehood. 
A  high  birth  rate  is  usually,  but  not  invariably,  Hnked  with  prosperity. 
The  foreign-born  population  of  the  United  States  has  apparently 
a  larger  percentage  of  children  than  the  native  population,  but  this 
excess  of  fecundity  is  probably  no  more  than  that  which  usually  is 
found  in  urban  populations  in  poor  districts,  and  the  high  infant 
mortality  commonly  found  among  this  foreign  element  more  than 
reduces  its  growth  to  the  level  of  native-born  Americans. 

The  Royal  Commission  in  New  South  Wales,  quite  recently  appointed, 
after  careful  study  and  thought,  decided  that  the  main  factor  in  the 
reduction  of  the  birth  rate  was :  "  A  diminution  in  fecundity  and  fertility 
in  recent  years;  due  to  the  deliberate  prevention  of  conception  and 
destruction  of  embryonic  life,  and  to  pathological  causes  consequent 
on  the  means  used,  and  the  practices  involved  therein."  The  remedy 
for  this  is  not  easy  to  apply;  all  nations  are  becoming  more  extravagant 
in  their  methods  of  living — automobiles  and  babies  may  be  incompatible 
possessions — if  we  have  one,  we  must  often  renounce  the  other. 

Infanticide  by  neglect  or  intention  undoubtedly  causes  the  death 
of  many  hundreds  of  infants  each  year.  Women  in  the  poorer  walks  of 
life  should  be  m-ged  to  nurse  their  children,  entirely  or  in  part,  as  long 
as  possible.  Part  breast-  and  part  bottle-feeding  is  much  better  than 
all  bottle  feeding;  weaning  should  never  be  done  prematurely  unless 
by  the  advice  of  a  physician.  Women  with  illegitimate  children  should 
be  kept  in  the  hospital  and  made  to  nurse  their  babies  until  after  the 
third  month.  After  this  age,  the  child  is  better  able  to  withstand  the 
perils  of  artificial  food,  and  the  mother,  from  her  association  with  the 
child,  has  perhaps  become  sufficiently  fond  of  it  to  make  an  effort  to 
protect  its  life.  If  a  child  is  torn,  and  no  one  is  with  the  mother  at 
the  time  of  its  birth,  the  danger  of  death  at  the  time  of  delivery  is 
greatly  increased,  and  the  secrecy  of  birth  may  induce  the  mother, 
under  certain  conditions,  to  destroy  the  child's  life. 

The  giving  of  opiates  to  children,  either  in  the  form  of  paregoric 
or  of  a  soothing  syrup,  is  pernicious  and  should  always  be  absolutely 
forbidden.  Overlying,  either  by  accident  or  design,  is  in  certain 
portions  of  this  and  other  countries  very  common;  an  infant,  of 
course,  should  never  sleep  in  the  same  bed  with  its  mother. 

Infant  life  insurance  and  burial  clubs  cause  the  death  by  neglect 
of  many;  statistics  prove  that  a  much  greater  number  of  children 
insured  and  in  burial  clubs  die  than  of  those  children  in  the  same  cities 
and  towns  who  are  without  such  insurance.  Coroners'  inquests  should 
be  rigid  and  impartial,  and  if  there  is  any  question  or  possibility  of 
infanticide,  the  case  should  be  thoroughly  investigated  and  proper 
punishment  imposed  on  the  guilty.  Of  864  children  dying  under  one 
week  of  age  in  Philadelphia,  inquests  showed,  according  to  Parry, 
that  94  were  "stillborn,"  210  died  from  "unknown  causes,"  293  from 


GENE  UAL  STATISTICS  59 

"asphyxia,"  02  from  "exposure  and  neglect,"  and  22  from  "want  of 
medical  attention."  In  these  cases  the  coroner's  pliysician  believed 
that  the  majority  of  those  which  he  examined  were  murdered. 

The  death  rate  per  thousand  is  well  known  to  be  much  higher  among 
illegitimate  than  among  legitimate  children.  An  interesting  fact, 
which  is  perhaps  not  always  appreciated,  is  that  in  large  cities  the  death 
rate  among  illegitimate  infants  is  much  greater  than  in  country  districts. 
In  Glasgow  in  1873  the  death  rate  for  illegitimate  infants  was  293 
per  thousand;  for  legitimate  infants,  154  per  thousand.  In  London 
in  1902  the  death  rate  of  illegitimate  children  was  almost  twice  as 
great  as  the  death  rate  of  legitimate  children.  The  infant  death  rate 
of  London,  as  a  whole,  exceeds  the  rural  infant  death  rate  by  about 
20  per  cent.  The  deaths  among  illegitimate  infants  in  London  exceeds 
the  rural  death  rate  among  illegitimate  infants  by  over  50  per  cent. 

According  to  Dr.  Norman  I\err,  in  1894  the  proportion  of  female 
inebriates  in  England  had  increased  greatly  in  the  few  years  preceding 
1894.  He  asserts  that  prison  experience  shows  a  distinct  increase  in 
excessive  drinking  among  women.  According  to  the  annual  death  rates 
from  alcoholism  in  England  and  Wales,  per  million  living,  from  the 
.year  1875  to  1904,  the  mortality  due  to  inebriety  is  distinctly  increasing. 
The  average  for  every  five  years  from  1875  to  1904  was:  1875  to  1879, 
25  deaths  per  million  living;  1880  to  1884,  29  deaths  per  million; 
1885  to  1889,  36  deaths;  1890  to  1894,  50  deaths;  1895  to  1899,  58 
deaths;  1900  to  1904,  71  deaths.  In  studying  these  figures  it  seems 
as  if  there  can  be  no  reasonable  doubt  that  alcoholism  is  increasing 
among  the  women  of  England  and  Wales,  although  some  allowance 
should  probably  be  made  for  the  more  accuiate  diagnosis  of  recent 
years.  Dr.  Scott,  quoted  by  Newman,  believes  that  alcoholism  is 
increasing  among  the  women  of  Scotland. 

Alcohol  is  a  distinct  poison  to  children,  but  the  number  of  deaths 
caused  by  the  giving  of  alcohol  direct  in  any  form  to  children  is  certainly 
very  small  in  the  United  States.  It  has,  however,  been  clearly  shown 
that  suffocation  in  bed  and  overlying  are  twice  as  common  on  Saturday 
as  on  any  other  night  in  the  week;  and  the  prevalence  of  drinking 
among  the  poor  on  that  night  is  proverbial.  An  alcoholic  mother 
rarely  supplies  her  baby  with  a  good  breast  milk,  and  what  is  perhaps 
more  important  is  the  fact  that  the  milk  from  such  a  mother  may  even 
contain  alcohol.  Alcoholism  among  women  is  perhaps  increasing  in 
America,  but  it  is  surely  less  common  than  in  England. 

Systematic  nursing  and  medical  care  are  wonderful  aids  in  the 
prevention  of  infant  mortality,  and  account  largely  for  the  difference 
between  the  infant  mortality  of  the  rich  and  poor.  Home  treatment, 
or  perhaps  better  say  maltreatment,  of  very  young  infants  often 
destroys  what  little  chance  of  life  the  infant  would  otherwise  have  had. 
The  poor  and  ignorant  classes  often  call  "the  doctor"  too  late  to  save 
the  patient. 

It  is  not  an  easy  task  to  form  an  accurate  idea  of  how  many  or  what 
proportion  of  infant  deaths  are  due  to  congenital  causes  and  those 


60  INFANT  MORTALITY 

diseases  wliieb,  if  ]i<)t  aetuully  congenital,  still  leaA'e  the  child  more 
susceptible  to  their  development  than  is  the  child  wht)se  jjarents  are 
free  from  such  diseases.  Herbert  M.  Rich,  in  686()  deaths  under  one 
year  of  age,  found  23.2  per  cent,  to  be  due  to  malformations,  congenital 
debility  and  premature  birth. 

In  Philadelphia  during  the  year  1915,  70  deaths  were  recorded  in 
infants  under  one  year  of  age  as  due  to  syphilis,  and  4  deaths  in  infants 
from  one  to  two  years  of  age  from  the  same  cause.  During  this  same 
year  there  were  848  premature  births  in  Philadelphia,  a  large  por- 
portion  of  which,  it  is  reasonable  to  suppose,  were  due  to  syphilis, 
which  is  certainly  responsible  for  many  premature  and  early  deaths. 

During  1911  and  1912,  in  New  York  City,  there  were  132,776  births, 
of  which  6749  were  stillbirths. 

The  following  figures  are  from  the  records  of  the  Board  of  Health 
of  New  York  City: 

Deaths  one 
month  and 
No.  of  births.  Stillbirths.  Illegitimate  births.  under. 

1911  .   .  66,537  3438  1559  8223 

1912  .   .  66,249  3311  1541  7675 

In  London  and  in  most  English  cities  the  mortality  from  prematurity 
and  atrophy  is  about  45  per  thousand,  these  deaths  almost  all  occurring 
in  the  first  three  months  of  life.  Smallpox,  malaria,  typhoid  fever 
and  tuberculosis  are  all  diseases  that  may  and  do  exert  an  influence  on 
the  infant.  Lead,  mercury  and  phosphorus  may  have  a  distinct 
antenatal  effect,  and  the  influence  of  alcohol  has  already  been  alluded 
to.  In  fact,  any  and  all  toxemias  may  influence  the  child  during 
intra-uterine  life. 

The  table  on  page  61  gives  the  causes  of  death  in  babies  less  than  one 
month  old  during  the  year  1912  in  New  York  City. 

Gastro-intestinal  diseases  are  not  only  the  most  common  diseases  of 
infancy  and  childhood,  but  they  are  also  responsible  for  more  deaths 
than  any  other  class  of  diseases.  Infantile  diarrhea  is  especially  apt 
to  occur  in  the  first  year  of  life,  although  very  common  in  children 
under  two  years  of  age.  Hot  weather,  bad  feeding  and  poor  hygiene 
are  the  chief  etiological  factors.  It  is  often  seen  in  epidemics,  is  very 
dangerous,  and  is  the  common  cause  of  deaths  among  infants  in  cities 
in  summer.  Epidemics  have  often  been  traced  to  infected  milk, 
although  one  must  remember  that  milk  may  be  infected  at  the  farm, 
in  transit,  or  by  the  consumer. 

Cases  of  this  disease  are  rare  among  the  rich,  compared  to  the 
number  one  sees  among  the  poor;  they  are  rare  in  the  country,  com- 
pared with  the  number  seen  in  the  cities.  The  diarrheal  death  rate 
is,  as  a  rule,  highest  in  those  countries  where  the  infant  mortality  is 
greatest.  Taking  42  of  the  largest  German  cities,  in  the  years  1904- 
5-6,  there  occurred  67,633  deaths  of  infants  under  one  year  of  age; 
of  these  28,422  were  due  to  gastro-intestinal  disease. 

The  records  of  the  Bureau  of  Health  of  Philadelphia  for  the  year 


GENERAL  STATISTICS 


61 


1915,  show  the  number  of  deaths  from  diarrhea  and   enteritis,  as 
follows: 

Jan.  Feb.  Mar.  Apr.  May.  June.  July.  Aug.  Sept.  Oct.  Nov.  Dec. 
Under  one  year  32  27  42  54  47  49  201  269  217  122  69  39 
1  to  2  years 


5 


6 


10 


37 


60 


44 


This  gives  a  total  of  1163  deaths  in  infants  before  the  end  of  the 
first  year,  and  only  213  deaths  during  the  second  year. 


Jan. 

Feb. 

Mar.JApr. 

May 

June 

July 

Aug. 

Sept. 

Oct. 

Nov. 

Dec. 

Total 

Erysipelas 

1 

2 

4 

3 

0 

3 

3 

2 

0 

0 

1 

0 

19 

Congenital    debility 

! 

icterus, atrophy.pre 

- 

maturity,  niarasmu 

s       120 

113 

120 

9.5 

134 

ill 

125 

121 

121 

121 

102 

105 

1388 

Gangrene 

0 

1 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

1 

Syphilis    . 

6 

4 

6 

9 

4 

3 

3 

2 

3 

4 

8 

5 

57 

Gonococcus   . 

0 

0 

0 

0 

1 

0 

0 

0 

0 

0 

0 

1 

2 

General  diseases,  pur 

- 

pura   hemorrhagica 

diabetes 

1 

0 

0 

0 

0 

0 

0. 

0 

0 

0 

0 

0 

1 

Convulsions  . 

8 

0 

3 

1 

2 

5 

3 

4 

0 

4 

0 

2 

32 

Bronchitis 

13 

6 

8 

2 

4 

0 

2 

3 

3 

5 

5 

5 

56 

Pneumonia    . 

28 

26 

14 

26 

6 

8 

10 

10 

10 

21 

26 

22 

207 

Influenza 

1 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

1 

Pertussis 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

2 

0 

2 

Diarrhea,  enteritis 

4 

6 

13 

11 

11 

7 

14 

13 

14 

10 

4 

7 

114 

Diseases  of  stomach 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

3 

3 

Hernia  and  intestina 

1 

obstruction 

0 

1 

1 

0 

0 

0 

0 

0 

0 

0 

0 

1 

3 

Congenital      malfor 

mations 

13 

11 

20 

3 

17 

12 

16 

11 

8 

17 

15 

13 

156 

Diseases  of  skin  anc 

adnexa    . 

1 

0 

1 

1 

0 

1 

1 

0 

0 

0 

0 

1 

6 

Diseases  of  kidney 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

1 

1 

Diseases  of  liver . 

0 

0 

0 

0 

0 

0 

0 

1 

0 

0 

0 

0 

1 

Meningitis     . 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

1 

0 

1 

Softening  of  brain 

0 

0 

0 

0 

0 

0 

0 

1 

0 

0 

0 

0 

1 

Tetanus    . 

3 

0 

0 

0 

0 

0 

0 

1 

0 

0 

0 

0 

4 

Causes    peculiar    t( 

) 

infancy,      umbilica 

1 

hernia,     atelectasis 

forceps  injury    . 

43 

47 

50 

38 

45 

31 

35 

37 

20 

45 

31 

37 

459 

Homicide,     piercing 

cutting   . 

1 

0 

0 

0 

1 

0 

0 

0 

0 

1 

0 

0 

3 

Homicide,        othe 

r 

means     . 

1 

0 

4 

0 

2 

1 

0 

0 

0 

0 

1 

0 

10 

External  violence 

2 

1 

1 

0 

0 

1 

0 

0 

0 

0 

0 

0 

5 

Accidental  drowning 

1 

0 

0 

0 

0 

1 

0 

0 

0 

2 

0 

0 

4 

Absorption  of  delete 

rious  gases   . 

1 

1 

0 

0 

0 

0 

1 

0 

0 

0 

1 

1 

5 

Acute  poisoning 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

Acute  abscess 

0 

0 

3 

0 

0 

0 

0 

0 

0 

0 

0 

1 

4 

Diseases  of  organs  o 

f 

locomotion  . 

0 

0 

0 

0 

0 

0 

0 

0 

1 

0 

0 

0 

1 

Diseases  of  lymphati 

system    . 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

Unspecified  causes 

0 

1 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

1 

In  certain  American  cities  it  has  recently  been  clearly  proved  in 
many  instances  that  this  enormous  summer  death  rate,  due  to  the 
diarrheal  diseases,  can  be  reduced.  Clean  milk  must  be  provided  for 
the  poor  at  a  nominal  cost,  and  this  milk  must  be  properly  modified 
for  children  of  different  ages  and  conditions.  A  campaign  of  education 
among  the  mothers  of  this  poor  class  must  be  carried  on  persistently 
and  continuousl}';  visiting  nurses  must  be  supplied;  and  fresh  air  and 
improved  hygiene  must  be  insisted  on.  It  is  not  asserting  too  much 
to  say  that  a  reduction  of  50  per  cent,  in  summer  infant  mortality  may 
be  accomplish(>d  by  these  means. 

It  is  an  old  truth  thoroughly  appreciated  by  American  physicians 


.62  INFANT  MORTALITY 

that  breast-fed  infants  do  well,  whether  they  belong  to  the  rich  or  the 
poor,  but  I  do  not  believe  that  it  is  appreciated  how  great  a  difference 
exists  in  the  infant  mortality  between  breast-fed  and  bottle-fed  infants. 
In  the  year  1903,  4075  infants  died  in  INIunich;  of  these  83  per  cent, 
were  artificially  fed.  In  Berlin  since  1885  the  census  gives  the  character 
of  the  feeding  of  all  living  children.  Taking  the  five  years,  1900  to 
1904,  only  9  per  cent,  of  the  deaths  occurred  in  breast-fed  babies,  and 
Budin  has  shown  that  only  about  9.5  per  cent,  of  the  infant  mortality 
in  Paris  occms  in  breast-fed  children.  Of  course,  breast  feeding  is 
usually  associated  with  other  favorable  factors,  and  bottle  feeding 
often  combined  with  many  unfavorable  associated  conditions,  but  the 
figures  are  truly  startling. 

The  importance  of  breast-feeding  as  a  means  of  reducing  the  infant 
mortality  rate  is  clearly  shown  by  the  statistics  which  follow: 

In  New  York  City  more  than  85  per  cent,  of  all  deaths  in  infants 
occur  in  the  bottle-fed.  In  Boston,  in  the  year  1911,  74  per  cent,  of 
all  infants  over  two  weeks  of  age  who  died  were  artificially"  fed,  and  in 
a  series  of  1000  cases  of  infants  studied  by  Armstrong,  in  Liverpool, 
22.8  per  cent,  of  the  artificially  fed  babies  died  in  their  first  year,  and 
only  8.4  per  cent,  of  the  breast-fed.  In  1908  the  Health  Department 
of  New  York  City  reported  that  of  1000  fatal  cases  of  enteritis  only 
90  were  in  breast-fed  infants. 

In  war  time  the  infant  mortality  often  declines  in  manufacturing 
centres,  in  spite  of  the  fact  that  the  general  mortality  rate  increases. 
During  the  siege  of  Paris,  1870-71,  it  is  claimed  the  general  mortality 
rate  doubled,  yet  the  infant  mortality  rate  declined  40  per  cent. 
Under  such  conditions  infants  do  not  die,  and  why?  In  times  of  war 
or  great  industrial  depression  the  poor  woman ,  having  no  work,  stays 
at  home  and  nurses  her  baby,  and  the  child  lives.  In  prosperity  she 
works  all  day,  gives  her  bab.y  the  bottle,  and  it  dies. 

This  is  borne  out  by  recent  statistics  compiled  in  Paris  where,  since 
the  beginning  of  the  present  war,  the  general  infant  mortality  has 
diminished,  more  babies  are  born  at  full  term,  and  fewer  are  abandoned. 
These  conditions  must  be  attributed  to  the  special  protection  extended 
to  expectant  mothers  and  to  infants  during  the  first  year  of  the  war. 

In  England  this  work  of  saving  the  babies  has  received  a  great 
impetus  since  the  outbreak  of  the  war,  more  infant  welfare  stations 
having  been  established  than  ever  before  in  the  same  period  of  time. 
During  the  first  eight  months  of  the  war  100  new  schools  for  the  instruc- 
tion of  mothers  were  founded,  man}'  of  which  f m*nished  meals  for  both 
expectant  and  nursing  mothers,  while  200  more  baby  stations  were 
planned  for;  all  this  in  towns  with  a  population  of  20,000  or  more,  to 
say  nothing  of  what  the  smaller  places  may  have  done. 

It  is  both  interesting  and  instructive  to  note  that  any  considerable 
variation  in  the  infant  death  rate  in  any  locality"  is  almost  invariably 
linked  with  a  corresponding  change  in  the  diarrheal  death  rate,  the 
mortality  from  other  causes  changing,  as  a  rule,  comparatively  little. 

The  factors  contributing  to  infant  mortality  are  so  many  and  varied 


GENERAL  STATISTICS  63 

and  the  difficulties  in  controlling  these  harmful  influences  are  so  great 
that  at  the  present  day  one  is  forced  to  admit  that,  while  the  prevent- 
able death  rate  is  very  large,  still  among  the  poor  there  must  neces- 
sarily be  a  high  death  rate. 

Bronchopneumonia  and  true  pneumonia  also  cause  not  a  small 
proportion  of  deaths  during  infancy,  the  majority  of  fatalities  from 
these  diseases  occurring  in  the  crowded  tenement  districts.  During 
the  year  1915  the  deaths  from  these  diseases  in  Philadelphia  were  as 
follows: 


Under  one  year. 

Jan. 

Feb. 

Mar. 

Apr. 

May 

June 

July 

Aug. 

Sept. 

Oct. 

Nov. 

Dec. 

Bronchopneumonia . 

59 

37 

53 

oo 

37 

23 

20 

18 

15 

30 

27 

58 

True  pneumonia 

21 

26 

19 

24 

12 

6 

11 

3 

8 

o 

10 

?.\ 

One  to  two  years. 

Bronchopneumonia . 

16 

15 

23 

15 

20 

10 

20 

IS 

15 

30 

27 

58 

True  pneumonia 

10 

11 

19 

21 

13 

7 

4 

2 

1 

4 

7 

12 

Total  deaths  from  bronchopneumonia  under  one  year  of  age,  432 
Deaths  from  bronchopneumonia  one  to  two  years,  182 
Deaths  from  true  pneumonia  under  one  year  of  age,  166 
Deaths  from  true  pneumonia  one  to  two  years.  111 

Several  years  ago  the  mayor  of  Huddersfield,  England,  offered  a 
gift  of  $5  to  every  child  born  in  his  town  that  lived  to  the  age  of  twelve 
months.  All  classes,  rich  and  poor,  were  included;  the  mortality  in  the 
Huddersfield  district  was  immediately  reduced  more  than  50  per  cent. 

In  Yonkers,  N.  Y.,  a  campaign  was  undertaken  in  1894,  having  as 
its  object  the  reduction  of  the  infant  mortality  rate.  The  physicians 
of  Yonkers,  aided  by  the  public  press,  established  milk  stations,  and 
instituted  and  carried  out  a  campaign  of  education  among  mothers. 
A  sanitary  inspection  of  the  tenement  district  was  adopted,  and  nurses 
were  appointed  to  visit  the  sick.  The  Board  of  Health  also  passed  a 
regulation  requiring  in  all  new  tenements  a  sufficient  amount  of  light 
and  air.  The  deaths  from  digestive  diseases  were  reduced  more  than 
50  per  cent.  Dr.  S.  E.  Getty  believes  that,  of  all  the  means  employed, 
the  most  important  was  the  establishment  of  the  milk  dispensaries. 

Holt,  in  the  following  table  of  statistics,  shows  the  decrease  in  infant 
mortality  as  the  result  of  a  campaign  waged  in  New  York  City  by  its 
Board  of  Health. 

1880 228  deaths  per  1000  infants  born  alive 

1902 168 

1908 .  144 

1911 120 

1912 109 

1913 102 

That  a  general  propaganda  against  infant  mortality  has  been  vigor- 
ously pushed  all  over  the  United  States  is  shown  by  the  census,  of  1880 
and  of  1890.  In  1880  the  general  infant  mortality  of  the  United  States 
was  246  per  thousand;  in  1890  it  had  fallen  to  159  per  thousand, 
and  during  the  same  period  it  is  gratifying  to  note  that  the  infant 
mortality  in  cities  decreased  from  303  to  184  per  thousand.  In  1914, 
there  were  reported  204  infant  welfare  stations  in  39  cities  and  towns 
of  the  United  States.    This  is  surely  a  record  to  be  proud  of. 


1891   .   . 

.   .   96 . 5  per  1000 

1901   .   . 

.   .   61.3 

1911   .   . 

.   .43.8 

1913   .   . 

.   .  37.3 

64  INFANT  MORTALITY 

The  liegister  of  Records  of  the  Department  of  Health  in  New  York 
City  shows  the  reduction  in  the  annual  death  rate  of  children  under 
five  years  of  age,  and  this  is  largely  attributed  to  the  use  of  pasteurized 
milk.    The  figures  are  as  follows: 

f  125.1  per  1000 
July  and  August  I     ac-  o         u 
[    38.8        " 

Since  1910  the  deaths  among  infants  under  one  year  of  age  in 
greater  New  York  have  dropped  as  follows : 

In  1910 ' 16,215 

In  1911 15,053 

In  1912 14,289 

In  France,  1874  to  1893,  the  average  infant  mortality  was  167  per 
thousand.  Ten  years  later,  in  1903,  it  was  only  137  per  thousand. 
In  Paris  it  was  only  101 ;  wonderful  Paris  has  the  smallest  birth  rate 
and  the  lowest  death  rate  of  any  large  European  city. 

The  physicians  of  the  United  States  have  accomplished  much  in  the 
last  ten  years,  and  yet  when  we  consider  how  remarkably  successful 
have  been  the  efforts  directed  to  save  infant  life,  should  we  not,  as  the 
representative  body  of  the  American  profession,  feel  chagrined  that 
we  have  not  accomphshed  more?  Certainly  50  per  cent,  of  all  infant 
deaths  at  the  present  day  are  preventable. 

Hospitals  for  infants  have  been  established  all  over  the  world,  and 
we  are  establishing  new  ones  almost  daily,  and  yet  some  physicians 
question  whether  they  do  good  or  harm.  Going  back  to  the  year  1871, 
we  find  that  29.82  per  cent,  of  all  the  children  born  in  Philadelphia 
died  before  the  end  of  their  first  year.  In  the  same  year,  in  the  found- 
ling ward  of  the  Philadelphia  Hospital,  73.65  per  cent.  died.  The 
death  rate  among  the  foundlings  was  43.83  per  cent,  more  than  among 
infants  of  the  same  age  of  Philadelphia.  These  children  were,  as  a 
rule,  in  fair  health  on  entering  the  Hospital.  Of  these  infants,  74.69 
per  cent,  died  from  diarrheal  diseases,  and  only  25.31  per  cent,  from 
all  other  causes.  At  this  period,  the  records  of  the  foundlings'  ward  in 
the  Philadelphia  Hospital  were  about  the  same  as  the  records  from  the 
foundling  hospitals  in  other  large  American  cities.  Dr.  A.  Jacobi, 
at  this  date,  had  the  courage  to  point  out  publicly  the  enormous 
mortality  in  the  foundling  institutions  of  New  York,  and  as  a  con- 
sequence was  asked  to  resign  from  the  staff'  of  the  Hospital  with  which 
he  was  connected. 

Van  Ingen  reports  a  series  of  738  cases  of  infants  in  an  institution  in 
New  York  City;  22  per  cent,  of  all  that  died  succumbed  during  the 
first  month.  The  total  mortality  during  the  first  month  among  all  the 
babies  born  in  the  institution  was  only  8  per  cent.,  but  48  per  cent,  died 
before  the  year  was  ended. 

Dr.  Knox,  of  Baltimore,  reports  a  series  of  200  cases  of  infants  in 


GENERAL  STATISTICS  05 

different  institutions  in  that  city  in  which  80  to  90  per  cent,  of  the 
deaths  occurred  before  the  end  of  the  first  year,  and  this  was  the  actual 
total  of  those  who  remained  in  the  institutions.  The  10  per  cent,  that 
survived  had  practically  all  been  sent  away  from  the  institutions  into 
the  care  of  foster  mothers. 

What  is  the  condition  in  our  infant  hospitals  at  the  present  day? 
My  personal  opinion  is  that  in  the  modern  infant  hospital,  where 
the  air  space  is  ample,  and  the  windows  are  kept  open  day  and  night; 
where  the  milk  is  the  best  and  the  milk-room  thoroughly  up  to  date; 
where  the  ratio  of  nurses  to  patients  is  not  less  than  one  to  five ;  where 
the  sick  are  promptly  isolated  from  the  well,  and  "mothering"  is 
understood — that  in  such  a  hospital  the  physician  is  an  optimist  and 
not  a  pessimist. 

Many  of  the  infants  will  die,  but  most  of  them  will  live.  If  one 
considers  that  many  of  those  who  die  are  "weaklings"  on  admission, 
and  that  the  greatest  proportion  of  deaths  occurs  in  the  first  three 
months  of  life,  one  is  apt  to  believe  that  the  best  of  the  modern  infant 
hospitals  are  worthy  institutions  and  should  be  supported.  Much 
depends  on  the  character  of  the  feeding;  but,  here  as  ever,  the  truth 
that  breast  feeding  is  better  than  bottle  feeding  is  well  exemplified. 

Of  300  infants  admitted  to  the  Dresden  Children's  Polyclinic  in 
1900  to  1901  there  were  53  deaths.  All  the  deaths,  53  in  number,  were 
among  the  bottle-fed  babies.  Among  93  breast-fed  babies,  during  the 
same  period,  in  the  same  hospital,  there  was  not  a  death.  Breast- 
feeding is  surely  a  powerful  measure  with  which  to  combat  death. 

According  to  the  census  of  1900,  the  infant  mortality  per  1000  in 
the  United  States  was  in  those  States  where  registration  was  in  force : 

Per  1000  births. 

District  of  Columbia 274 . 5 

Rhode  Island 197.9 

Massachusetts 177.8 

New  York 159.8 

Connecticut 156.8 

Maine 144.1 

New  Hampshire 172.0 

New  Jersey 167 . 4 

Vermont ■ 122.1 

Michigan 121.3 

The  census  of  1900  shows  the  returns  for  infant  mortality  from  many 
cities  and  towns  of  the  United  States.  The  infant  mortality  in  some 
of  these  cities  is  very  high,  over  400  per  1000  in  Charleston,  S.  C. 
A  number  of  them  show  a  mortality  above  300,  and  more  than  100 
cities  exhibited  an  infant  mortality  above  175  per  1000. 

The  important  point  to  be  decided  is  as  to  the  influence  which  has 
been  exerted  on  this  infant  death  rate  in  recent  years.  Have  we  been 
able  to  reduce  in  any  appreciable  degree  this  great  and  unnecessary 
waste  of  infant  life?  A  careful  study  will  show  that  there  has  recently 
been  a  great  saving  of  life,  and  much  will  surely  be  accomplished  in 
the  future. 
5 


66  INFANT  MORTALITY 

In  1903  the  infant  mortality  of  France  was  137.  In  the  previous 
twenty  years  it  was  167,  and  yet  this  death  rate  ought  to  be  still  more 
greatly  reduced,  for  we  know  that  Ireland  has  an  infant  death  rate 
below  100.  Norway  in  1902  had  an  infant  death  rate  of  75,  and 
Sweden  107  per  1000. 

Of  all  European  countries,  Russia  has  the  highest  infant  death  rate, 
270  per  1000.  Germany  has  the  next  highest,  averging  in  recent  years 
a  little  over  200  per  1000.  Medical  science  and  skill  have  reached 
a  very  high  plane  in  both  these  countries,  and  infant  mortality  has 
been  greatly  reduced  during  the  last  thirty  years.  It  is  to  be  hoped  that 
the  useless  waste  of  life  in  these  two  countries  will  quickly  be  much 
more  distinctly  diminished,  and  it  is  believed  they  will  soon  show  as 
great  a  reduction  as  has  been  brought  about  in  France. 

There  has  been  a  great  decrease  in  the  proportion  of  infants  dying 
under  one  year  of  age  in  the  United  States  during  the  last  twenty  years. 
The  infant  mortality  in  1880  was  246  per  1000;  in  1890  it  had  fallen 
to  159  per  1000.  During  the  same  period  the  mortality  in  the  cities 
of  the  United  States  fell  from  303  to  184  per  1000. 

Many  figures  might  be  quoted  showing  that  in  recent  years  infant 
mortality  has  distinctly  lessened.  In  London  in  January,  1908,  the 
deaths  of  infants  under  one  year  of  age  to  1000  births  was  115.  Accord- 
ing to  George  B.  Mangold,  U.  S.  Department  of  Commerce  and 
Labor,  the  infant  mortality  in  New  York  City  iii  1891  was  241.9 
per  1000;  in  1900  it  was  191.7  per  1000;  and  in  1906  it  was  167.8 
per  1000.  In  the  same  city  the  death  rate  of  children  under  five  years 
of  age  was  96  per  1000  in  1891 ;  in  1896  it  had  fallen  to  77.5  per  1000, 
in  1900  the  mortality  under  five  years  of  age  was  only  67  per  1000; 
and  in  1904,  it  was  54  per  1000.  In  the  same  community  the  deaths 
from  measles,  scarlet  fever  arid  diphtheria  have  become  distinctly 
less;  and  diarrheal  diseases  in  small  children  have  decreased  62  per 
cent,  since  1881. 

School  nurses  are  now  provided  and  medical  inspection  of  schools 
is  today  well  recognized  and  practised  in  many  of  our  large  cities. 
According  to  Dr.  W.  M.  L.  Cophn:  "A  necessity  for  medical  attention 
was  detected  in  27,481  children  in  the  schools  of  Philadelphia  in  1905, 
and  31,544  children  in  1906."  Dr.  A.  C.  Abbott,  formerly  chief  of 
the  Bureau  of  Health  pf  Philadelphia,  shows  that  in  the  years  1903-5 
a  distinct  decrease  in  the  infant  death  rate  occurred.  Philadelphia 
shows  a  very  decided  decrease  in  infant  mortality  since  1897. 

Thomas  A.  Buckland,  City  Chemist  for  St.  Louis,  states  that  there 
has  been  a  decrease  in  infantile  mortality  in  that  city  since  1904. 
W.  Ernest  Wende,  M.D.,  Health  Commissioner  of  Buffalo,  states  that 
infant  mortality  is  decreasing  in  that  city.  Samuel  E.  Allen,  Health 
Officer  of  Cincinnati,  states  the  proportion  of  deaths  of  children  under 
two  years  of  age  to  the  total  mortality  has  decreased  considerably 
since  1886.  In  the  year  1886  it  was  32.56  per  cent.;  in  the  year  1906 
it  had  decreased  to  21.92  per  cent. 

Milwaukee  and  Minneapolis  and  the  nine  largest  cities  in  the  State 


GENERAL  STATISTICS  67 

of  New  York,  according  to  George  W.  Goler,  M.D.,  show  a  decrease 
in  infant  mortality: 

The  following  have  occurred  to  me  as  being  important  factors 
in  lessening  infant  mortality: 

Abatement  of  nuisances. 

Milk  inspection:  milk  dispensaries;  visiting  nurses. 

Free  antitoxin. 

Improved  sanitation. 

Good  food. 

Education  of  girls  and  married  women  in  the  duties  and  requirements 
of  motherhood. 

Maternity  fund  in  all  industrial  establishments  where  married 
women  are  employed. 

Care  of  poor  pregnant  women  before  and  after  confinement. 

Laws  carefully  protecting  all  children  who  are  cared  for  by  private 
individuals,  apart  from  their  parents;  rigid  enforcement  of  these 
laws. 

Elementary  principles  of  hygiene  taught  in  all  schools,  public  and 
private. 

Nursing  of  all  babies,  as  far  as  possible,  by  their  mothers. 

Sending  children  to  the  country  in  summer. 

Pasteurization  of  milk  during  the  hot  months. 

Farming  out,  under  proper  medical  supervision,  of  foundlings  and 
institution  infants,  and  the  appointment  of  nurses  to  visit  these  infants 
regularly. 


CHAPTER  V. 
HEREDITY. 

We  derive  certain  characters  from  our  parents,  and  certain  characters 
from  our  progenitors  other  than  our  parents.  The  entire  body  is, 
as  it  were,  built  up  of  myriads  of  units,  each  unit  inherited  from  some 
ancestor.  It  is  important  to  remember  that  the  child  inherits  not  only 
certain  physical  characters,  as  height,  features,  color  of  eyes,  etc.,  but 
that  mental  and  moral  characters  are  also  inherited,  such  as  moral  sense, 
ambition,  industry,  activity;  and  there  is  strong  evidence  to  prove  that 
a  trait  or  fundamental  principle  absent  in  both  parents  cannot  be 
present  in  their  child,  also  that  some  defect  that  is  marked  in  both 
parents,  especially  if  there  is  consanguinity  of  the  parents,  is  apt  to  be 
present  in  their  children.  For  instance,  it  has  been  estimated  that 
almost  one-third  of  the  children  of  deaf-mutes,  if  there  is  consanguinity 
in  the  parents,  are  deaf,  whereas  only  one-tenth  of  the  children  of  such 
parents  are  deaf  when  the  parents  are  not  blood  relatives.  Deafness 
may  arise  from  a  great  many  causes,  and  the  possibility  of  this 
cause  being  found  in  both  parents  is  much  more  likely  if  they  are 
consanguineous. 

The  inheritance  of  one  mental  or  physical  property  does  not  depend 
upon  the  inheritance  of  others;  for  instance,  one  child  in  a  family 
may  have  straight  hair,  another  curly  hair,  while  both  may  have 
blue  eyes.  In  fact,  when  the  parents  and  grandparents  are  known, 
many  physical  characteristics  of  the  children  may  be  explained.  An 
inherited  condition — for  instance,  hemophilia — may  be  transmitted  by 
an  apparently  normal  person. 

Man  begins  as  a  single  cell,  the  fertilized  ovum,  and  the  organism 
is  built  up  by  cell  division.  As  evolution  proceeds  environment 
assists  in  producing  certain  changes;  i.  e.,  certain  characters,  which 
may  formerly  have  been  essential,  have,  owing  to  changes  in  environ- 
ment, become  less  useful  or,  in  fact,  only  a  hindrance,  and  these 
characters  which  are  no  longer  of  any  use  or  assistance  tend  to  disap- 
pear. As  development  progresses  the  environment,  if  it  is  to  suit 
accurately  the  new  individual,  must  also  change. 

The  embryo  of  man  shows  at  a  certain  stage  of  its  embryonic  life 
an  arrangement  quite  analogous,  as  far  as  the  large  bloodvessels  are 
concerned,  to  that  found  in  the  gills  of  fish.  This  would  tend  to 
indicate  that  the  progenitors  of  man  were  more  or  less  aquatic  animals ; 
but,  the  human  embryo  not  needing  any  apparatus  similar  to  the 
gills  of  fish,  these  have  disappeared  except  for  such  scant  evidences  of 
their  former  existence  as  the  branchial  clefts  and  arches.  Changes  of 
this  type,  called  regressive,  are  of  course  brought  about  only  slowly, 


HEREDITY  '  69 

;iii(l  <\vv  ill  marl\('(l  contrast  to  other  cliai'actcristics  spoken  of  as 
pl•()gl•essi^'e,  which  are  in  keeping  with  the  evohition  of  the  in(h\idual 
and  its  changed  environment.  By  this  method  of  regressive  and 
progressive  changes  which  take  place  in  all  of  the  organs  and  tissues 
of  the  body  the  gradual  development  of  the  higher  animals  occurs. 

Children  may,  and  not  uncommonly  do,  show  mental  and  physical 
traits  which  were  not  present  in  either  parent,  but  were  inherited  from 
some  ancestor.  All  that  environment  can  do  is  to  modify  the  inborn 
characters.  Environment  and  training  are  certainly  the  direct  causes 
of  acquired  characters  in  the  individual,  and,  if  the  same  environment 
persists,  these  characters  may  appear  in  the  oflFspring.  If,  however, 
the  special  environment  that  has  brought  about  the  acquired  character 
is  not  present,  the  acquired  character  usually  ceases  to  reappear  in 
the  offspring.  Characters  disappear  sooner  or  later  when  they  cease 
to  be  the  subject  of  selection,  ^"ariations  occur  in  all  directions,  and 
it  is  the  environment  which  is  influential.  If  the  transmission  of 
acquired  characters  has  played  an  important  part  in  evolution  it  has 
come  about  by  the  selection  of  inborn  variations. 

Acquired  characters  may  be  transmitted,  but  it  is  not  a  common 
or  usual  occurrence;  the  evidence  or  proof  that  acquired  characters 
are  frequently  inherited  is  insufficient;  but  as  most  competent  observers 
attach  a  certain  amount  of  weight  to  this  idea,  it  may  be  accepted 
tentatively  as  an  occasional  fact,  and  its  acceptance  and  belief  may  do 
good  by  stimulating  the  better  side  of  our  natures.  Undoubtedly 
acquired  characters  are,  as  a  rule,  simply  normal  variations  and  the 
natural  transmission  of  such  variations;  if  suited  to  the  individual's 
environment,  they  are  permanent  and  progressive;  if  not  adapted  to 
the  environment  they  are  more  or  less  rapidly  eliminated.  In  order 
to  believe  that  the  inheritance  of  acquired  characters  is  common  or 
usual,  one  must  also  believe  that  it  is  possible  for  this  acquired  char- 
acter to  exert  some  specific  and  definite  action  on  the  germ  cell  itself, 
and  it  is  certainly  improbable  that  some  characters,  developed  perhaps 
in  middle  adult  life,  could  produce  this  effect. 

Environment  can  only  modify  characters;  it  can  not  originate 
them;  and  it  is  self-evident  that  each  specie  is  in  the  environment 
best  adapted  to  its  development.  Use  will  develop  both  mind  and 
body,  and  environment  is  certainly  the  cause  of  acquired  characters 
developing  or  appearing  in  an  individual,  but  environment  rarely,  if 
ever,  produces  changes  in  the  inborn  characters. 

It  is  important  to  appreciate  that  diseases  in  the  parent,  such  as 
syphilis,  rheumatism,  or  acute  alcoholism,  do  produce  mental  and 
physical  diseases  in  the  oflFspring;  but  the  diseased  condition  or  taint 
or  inherent  weakness  is  in  these  cases  transmitted  directly  to  the 
germ  cell,  and  normal  heredity  diflFers  from  diseased  heredity  as  normal 
tissue  differs  from  diseased  tissue.  If  this  diseased  oflFspring  is  not 
placed  under  the  best  environment  and  given  proper  medical  treatment 
it  tends  to  be  eliminated,  and  disappears  either  in  the  first  or  succeed- 
ing generations.     If  the  environment  and  treatment  are  proper  and 


70  HEREDITY 

suitable,  it  may  in  the  first  or  later  generation  return  to  the  normal 
standard. of  its  progenitors.  Heredity  is  constructive,  not  destructive; 
it  tends  to  build  up,  not  to  tear  down;  and  will,  if  assisted,  always 
do  its  full  share  toward  restoring  the  individual  to  the  normal  for 
its  species. 

Variations  are  not  always  of  the  same  kind  or  type,  and  the  persist- 
ence or  disappearance  of  these  variations  depends  on  the  environment. 
The  descendants  tend  to  inherit  these  variations,  some  in  a  greater, 
others  in  a  less  degree,  and  with  changing  environment  and  selection 
certain  new  characters,  as  sight  and  hearing,  are  evolved.  Variations 
are  of  common  occurrence,  but  need  enviromnent  to  complete  the 
process  of  evolution.  As  environment  changes,  the  species  must 
change,  else  it  would  be  destroyed. 

The  effect  produced  by  environment  is  clearly  shown  by  the  well- 
known  experiments  of  Nageli.  He  removed  some  Alpine  plants  from 
their  usual  location  and  transplanted  them  to  the  rich  and  fertile  soil 
of  the  Botanical  Gardens  in  Munich.  Under  the  new  environment  the 
plants  and  foliage  became  much  more  luxuriant,  and  the  seeds  from 
these  plants  also  produced  this  new  and  abundant  growth.  After 
thirteen  years  of  such  cultivation  and  luxuriant  growth  the  plants 
differed  greatly  from  their  original  stunted  and  sparse  forms.  When, 
however,  these  plants  were  removed  back  to  the  original  poor  soil 
of  their  Alpine  environment,  they  quickly  lost  all  their  acquired 
luxuriance  of  foliage  and  growth,  and  returned  to  their  former  stunted 
and  dwarfed  condition.  This  experiment  adds  much  weight  to  the 
theor}^  that  acquired  characters  can  and  often  will  be  inherited  if  the 
offspring  be  placed  in  the  same  conditions  of  environment  as  the 
parents  were  living  in  when  the  change  in  their  characters  occurred; 
and  while  it  tends  to  show  that  these  acquired  characters  can  undoubt- 
edly be  caused  by  environment  and  can  be  transmitted,  still,  there 
was  no  permanency  to  these  acquired  characters  except .  while  the 
changed  environment  persisted. 

It  is  well  known  that  the  cells  of  the  central  nervous  system  do  not 
multiply  after  birth;  they  of  course  develop,  and  gradually  assume 
certain  functions;  but  no  new  nerve  cells  are  produced,  and,  once 
destroyed,  they  are  never  reproduced.  Evolution  in  the  higher 
animals  as  seen  in  man  means  an  increase  in  the  size  of  the  brain 
and  a  consequent  increase  in  the  intelligence;  but  we  have  as  yet  no 
proof  of  the  possibility  of  parents  being  able  by  acquiring  brain  cells 
to  transmit  any  added  number  of  brain  cells  to  their  oft'spring.  The 
difference  between  man  and  the  higher  apes  is  especially  noticeable 
in  the  brain,  and  all  records  of  man  show  that  he  has  not  changed  any 
in  brain  capacity. 

In  the  consideration  of  the  characters  inherited  from  our  immediate 
parents  and  progenitors,  it  is  of  course  true  that  changes  in  environ- 
ment accomplish  much,  and  that  characters  acquired  by  the  parents 
may  appear  in  the  offspring,  during  many  or  all  succeeding  generations, 
if  the  offspring  live  under  the  same  conditions  as  the  parents,  and 


HEREDITY  71 

the  environment  does  not  cliange.  But  it  is,  nevertheless,  true  that 
man  has  changed  very  httle,  if  any,  in  stature  and  brain  capacity 
during  the  past  5000  years.  As  far  back  as  the  reindeer  age,  skeletons 
of  men  and  women  show  height  and  brain  capacity  to  have  been  about 
the  same  as  in  the  highest  types  of  man  today,  and  the  skulls  show 
no  changes  in  the  jaw  or  frontal  bones.  The  characters  of  a  race 
undoubtedly  change  very  little  from  generation  to  generation;  in- 
dividuals differ  sufficiently  in  looks,  voice,  external  appearance  and 
temperament  to  be  recognized  and  grouped,  and  these  slight  variations 
always  occur  in  races. 

The  individual  inherits  one-half  of  his  characters  from  the  two 
parents,  one-fourth  from  the  four  grand-parents,  one-eighth  from  the 
great-grandparents,  one-sixteenth  from  the  great-great-grandparents, 
and  so  on.  This  is  true  not  so  much  in  an  individual  case^as  when  large 
numbers  of  individuals  are  observed  in  the  aggregate. 

Galton  traced  the  family  histories  of  parents  of  unusual  mental 
capacity,  and  proved  conclusively  that  these  superior  and  unusual 
mental  characters  were  inherited,  and  the  offspring  of  such  parents 
were  superior  mentally  to  the  offspring  of  parents  mentally  inferior. 
Parents  with  unusual  mental  powers  will  transmit  such  powers  to 
their  offspring,  even  if  the  mental  powers  of  the  parents  have  not  been 
developed  by  educational  methods  and  environment — hence  the  mental 
powers  of  a  child  are  largely  decided  before  he  is  born.  This  does  not 
imply  that  the  individual's  mental  powers  may  not  be  improved  by 
education  and  environment;  but  the  mental  powers  of  the  child  will 
be  the  same  whether  the  parents  were  educated  or  not.  The  hope  of 
improving  the  race  by  giving  special  care  to  the  weak  and  feeble- 
minded is  fallacious,  and  marriage  and  procreation  by  such  parents 
can  only  tend  to  lower  the  general  tone  of  the  race. 

Heredity  has  been  defined  as  "the  inheriting  of  certain  qualities  or 
tendencies,  or  the  tendency  manifested  by  an  organism  to  develop 
in  the  likeness  of  its  progenitors." 

"  Degeneracy  is  the  absence  or  loss  of  that  degree  of  development  or 
energy  seen  in  the  ancestry  of  the  organism."  Heredity  is  a  tendency 
to  develop  the  type  of  the  ancestor.  Degeneracy  is  a  tendency  to  a 
lower  type  than  the  ancestor.  All  evolution  results  from  variation  and 
heredity.  If  type  a  is  to  become  b  by  evolution,  some  individuals  of 
a  must  vary  toward  b,  and  this  variation  must  be  inherited  and  trans- 
mitted until  a  finally  becomes  b.  The  ovum  and  spermatozoon  must 
bear  in  themselves  all  the  characters  that  are  inherited  from  their 
parents  and  ancestors. 

Environment  is  a  potent  cause  in  the  production  of  variations. 
Heredity  should  and  does  imply  merely  a  single  link  in  a  long  chain. 
Degeneracy  may  be  inherited  or  it  may  be  acquired;  it  is  a  mere 
accident  in  a  long  line  of  heredity. 


CHAPTER  VI. 
CONGENITAL  MALFORMATIONS. 

BRAIN  AND  SPINAL  CORD. 

Meningocele,  cephalocele,  and  hydrencephalocele  are  hernise  of 
certain  portions  of  the  cranial  contents,  either  through  an  abnormal 
opening  in  the  bony  skull  or  along  one  of  the  lines  of  suture  or  fissures. 
The  openings  through  which  the  cranial  contents  protrude  are  found  in 
the  occipital,  nasal,  parietal,  and  temporal  regions. 

Etiology. — The  etiology  is  rather  obscure.  Hornke  and  Hertwig 
produced  similar  deformities  in  some  animals  by  chronic  poisoning  of 
the  parents  before  impregnation,  and  in  others  by  injuring  the  ovum. 
Von  Bergmann  claims  that  a  misturning  of  the  cerebral  sac  is  the 
important  factor  in  its  causation. 

Pathological  Anatomy. — The  opening  in  the  skull  is  usually  small, 
and  the  dura  mater  does  not  protrude,  only  the  arachnoid  and  pia 
mater  escaping  from  the  cranial  cavity.  The  membranes  are  often 
greatly  thinned  by  the  distention  of  the  contained  fluid.  Small  tumors 
are  the  more  common,  and  are  less  apt  to  contain  brain  tissue. 

Meningocele. — A  meningocele  contains  the  internal  membranes  of 
the  brain,  and  these  membranes  are  usually,  but  not  invariably, 
distended  with  fluid.  The  opening  into  the  brain  is  generally  small. 
Fluctuation  is  present  in  the  tumor,  but  not  pulsation. 

Symptoms. — Bimanual  palpation,  one  hand  on  the  tumor,  the  other 
on  the  fontanelle,  will  disclose  increased  tension  in  the  fontanelle, 
unless  the  opening  into  the  cranial  cavit}^  has  become  occluded.  If 
the  sac  does  not  rupture,  and  is  not  of  large  size,  a  meningocele  may 
produce  few,  if  any,  symptoms.  If,  however,  it  becomes  progressively 
larger  and  the  walls  thinner,  the  nutrition  of  the  enveloping  skin  and 
scalp  tissue  becomes  impaired,  and  infection  and  bursting  become 
more  likely. 

Diagnosis. — ^The  diagnosis  is  usually  easy.  The  location  of  the  tumor 
is  significant;  its  partial  reduction  by  pressure  and  fluctuation,  if 
present,  help  to  confirm  the  diagnosis.  If,  in  addition  to  this,  there 
is  pulsation  and  pedunculation  the  diagnosis  is  rendered  practically 
certain. 

Treatment. — Surgery  offers  the  only  hope  for  the  patient.  This 
consists  in  the  removal  of  any  fluid  the  tumor  may  contain,  and  the 
closure  of  the  hernial  opening.  It  must  be  borne  in  mind  that  young 
children  stand  long  operations  badly.  If  hydrocephalus  is  present, 
the  result  is  apt  to  be  unfavorable.  If  the  tumor  is  small,  this  adds 
to  the  probable  success  of  the  operation.    As  a  rule,  the  result  of  the 


Fig.  2. — Meningocele  in  a  child  aged  four  months. 


Fig.  .3. — Meningocele. 


Fig.  4. — Meningucolc,  diilil  ■A'^al  seven  months. 


74 


CONGENITAL  MALFORMATIONS 


operation  in  meningocele  is  much  more  favorable  than  in  enceplialocele 
or  liydrencephalocele. 

Encephalocele. — This  consists  of  not  only  the  membranes  of  the 
brain  but  also  of  brain  tissue.  The  tumor  does  not  connect  with 
any  of  the  ventricles,  and,  if  fluid  is  present,  it  is  in  the  outer  portion 
of  the  sac,  immediately  beneath  the  skin  and  underlying  tissues.  The 
opening  into  the  skull  is  usually  larger  than  in  a  meningocele,  and  the 
tumor  is  generally  small  and  not  pedunculated  as  in  a  meningocele. 
Pulsation  is  often  present,  and  the  tumor  is  with  difficulty  reduced  by 
pressure;  cerebral  symptoms  commonly  follow  efforts  at  reduction. 

Treatment. — The  treatment  is  entirely  surgical.  The  smaller  the 
tumor  the  better  is  the  prognosis;  although,  as  surgery  presents  the 
only  hope,  the  child  should  be  given  the  chance  for  its  life  that  surgery 
offers.  Much  depends  on  the  child's  physical  condition,  the  mainte- 
nance of  all  its  vital  forces,  and  on  the  care  of  a  skilled  pediatrician, 
as  w^ell  as  upon  the  surgical  technic  employed.  Unless  such  combined 
care  is  possible,  surgical  interference  is  useless. 


Fig.  .5. — Encephalocele.  child  three  days  old. 


Hydrencephalocele. — This  consists  of  a  portion  of  brain  tissue 
enclosing  a  cavity  filled  with  fluid  which  communicates  with  a 
lateral  ventricle,  the  entire  mass  being  covered  externally  with  brain 
membranes.  The  tumor  can  not  be  reduced,  is  usually  of  large  size, 
and  is  apt  to  be  pedunculated.  The  fluid  in  this  form  is  in  the  interior 
of  the  mass,  and  gives  a  sense  of  deeper  fluctuation  than  in  the  other 
two  forms;  moreover,  this  form  may  be  associated  wdth  hydrocephalus. 
It  is  the  most  serious  of  all  brain  hernise,  and  offers  no  hope  of  cure  by 
surgical  means.  The  diagnosis  of  this  variety  from  meningocele  and 
encephalocele  is  important,  as  operation  offers  some  hope  in  the  last 
two   conditions. 

Acute  Hydrocephalus. — Acute  hydrocephalus  is  associated  with 
inflammation  of  the  base  of  the  brain,  and  is,  as  a  rule,  tubercular. 


BRAIN  AND  SPINAL  CORD  75 

An  increase  of  finid  is  always  found  in  acute  meningitis  of  all  forms, 
but  the  quantity  of  effusion  into  the  ventricles  is  usually  small.  As  a 
consequence  of  the  small  amount  of  effusion  in  acute  hydrocephalus, 
associated  as  it  is  with  meningitis,  the  head  rarely  attains  any  great 
size.  It  is  usually  the  result  of  tuberculous  meningitis,  is  the  most 
common  form  of  brain  inflammation  seen  in  children,  and  is  almost 
invariably  fatal.  Tuberculous  meningitis  will  be  found  described  in 
full  under  "Diseases  of  the  Nervous  System." 

Chronic  External  Hydrocephalus. — Chronic  external  hydrocephalus 
is  rarg  as  compared  with  the  internal  form.  It  may  be  the  result 
of  hemorrhage  of  the  meninges,  pachymeningitis,  or  congenital  mal- 
development  of  the  brain,  the  latter  cause  producing  the  most  typical 
cases.  The  convolutions  are  flattened  and  atrophied  from  the  pressure 
of  the  fluid  situated  outside  of  the  brain  substance  between  the  dura 
and  arachnoid.  If  present  in  large  and  increasing  quantities  the  fluid 
may  cause  a  progressive  enlargement  of  the  head,  similar  to  that  seen 
in  the  internal  variety  of  the  disease;  usually,  however,  the  amount 
of  fluid  is  small,  and  the  distention  and  pressure  only  slight. 


Fig.  6. — Chronic  internal  hydrocephalus,  child  aged  seven  nionths. 

Chronic  Internal  Hydrocephalus. — Congenital  hydrocephalus  is 
almost  always  of  the  internal  variety.  In  this  form  the  lateral  ventricles 
are  distended  with  fluid,  the  brain  substance  being  stretched  and  thin 
because  of  the  great  pressure.  The  fontanelles  are  much  increased 
in  size  as  the  jesult  of  a  large  amount  of  contained  fluid,  and  the 
bones  of  the  head  are  more  or  less  forced  apart. 

Etiology. — Evidences  of  hydrocephalus  may  be  present  to  a  marked 
degree  at  birth,  but  more  often  they  are  only  slight,  if  present  at  all, 
and  commonly  the  infant  does  not  show  any  manifestations  of  the 
disease  until  it  is  some  wrecks  of  age.  Among  the  systemic  causes 
capable  of  producing  the  disease  may  be  mentioned  alcoholism, 
syphilis,  heredity,  and  trauma  during  pregnancy.  Among  the  local 
causes  are  meningitis,  disease  of  the  choroid  plexus,  leptomeningitis, 
the  pressure  of  brain  tumor,  and  obliteration  of  the  foramen  of 
Magendie.  The  disease  may  be  congenital  or  acquired.  In  a  certain 
proportion  of  cases  hydrocephalus  will  be  found  associated  with  rickets, 
and  in  my  experience  these  cases  are  the  most  hopeful.     Cases  have 


76  CONGENITAL   MALFORMATIONS 

l)ee]i  rei)urle(l  wliert'  the  ]iy(]r()ce])lia.lii.s  lias  Followed  a  successful 
operation  tor  spina  bifida  or  enceplialocele.  The  salt  content  of  the 
cerebrospinal  fluid  is  very  low  and  is  of  the  natrium  variety.  The 
protein  elements  in  the  fluid  are  also  very  low. 

Pathological  Anatomy. — The  brain  shows  an  accumulation  of  fluid 
in  the  ventricles  and  the  septum  lucidmn  partly  destroyed  by  pressure. 
The  brain  is  anemic,  and  it  may  be  difficult  to  differentiate  between 
the  gray  and  the  white  matter.  The  ependyma  is  generally  thickened 
and  anemic.  Other  congenital  deformities  may  also  be  present.  A 
chronic  meningitis,  usually  basilar  in  type,  may  be  found,  and  the 
choroid  plexus  may  show  inflammatory  changes.  The  foramen  of 
Magendie  may  be  obliterated,  and  a  brain  tumor  may  be  present. 
The  specific  gravity  of  the  fluid  varies  from  1005  to  1007. 

Symptoms. — The  most  noticeable  symptom  is  the  large  size  of  the 
head,  which  may  be  so  large  as  to  cause  the  death  of  the  child  during 
its  birth.  The  forehead  is  bulging,  tlie  anterior  fontanelle  widely  dis- 
tended, and  the  frontal  and  parietal  bones  are  often  greatly  separated. 
The  anterior  fontanelle  is  tense  and  bulging,  the  eyes  protrude,  and 
the  cornea  is  partly  covered  by  the  lower  eyelid,  the  w^hite  sclera  show- 
ing above.  The  skin  covering  the  bones  of  the  head  is  stretched,  and 
the  superficial  veins  dilated.  The  head  is  wedge-shaped,  the  apex 
being  formed  by  the  chin.  The  eyes  have  a  downward  direction  as  the 
result  of  pressure  upon  the  orbital  plates  of  the  frontal  bone,  and 
nystagmus  and  strabismus  may  occur.  The  hair  is  scanty  and  dry, 
and  there  is  often  inability  to  hold  the  head  erect.  The  mental  powers 
are  usually  more  or  less  deficient,  although  if  the  fluid  accumulates 
slow'ly  a  fair  degree  of  mentality  may  be  present.  Atrophy  of  the 
optic  nerves  was  observed  in  a  few^  of  my  cases  but,  as  a  rule,  only  in 
those  in  whom  the  pressure  was  extreme.  The  arms  and  legs  may  be 
more  or  less  rigid,  and  the  hands  tightly  closed;  or  the  extremities 
may  be  relaxed  and  flaccid.  The  reflexes  are  usually  exaggerated. 
The  pupils  are,  as  a  rule,  equal  and  are  more  apt  to  be  contracted  than 
dilated.  Convulsions  occur  in  a  fair  proportion  of  cases.  A  slight 
increase  in  the  hydrocephalic  fluid  very  often  produces  marked  symp- 
toms, providing  the  bones  of  the  cranial  vault  are  firmly  ossified; 
whereas,  in  certain  cases,  if  the  anterior  fontanelle,  frontal,  and 
parietal  sutures  are  still  more  or  less  membranous,  the  bony  w^alls 
are  somewhat  elastic,  and  the  symptoms  may  be  very  slight. 

Diagnosis. — It  has  been  demonstrated  by  Theobold  Smith,  Arthur 
I.  Kendall,  and  many  others  that  there  is  an  available  carbohydrate 
in  the  normal  cerebrospinal  fluid  that  directly  influences  the  activity 
of  the  bacteria.  Toxins  are  not  produced  in  the  cerebrospinal  fluid 
in  the  presence  of  this  carbohydrate,  and  the  carbohydrate  that  the 
normal  cerebrospinal  fluid  contains  is  generally  believed  to  be  a  form 
of  non-fermentable  dextrose.  This  carbohydrate  of  the  normal 
cerebrospinal  fluid  is  the  first  element  attacked  by  the  bacteria  after 
their  entrance  into  the  central  nervous  svstem.     The  flora  which 


BRAIN  AND  SPINAL  CORD  77 

ordinarily  is  represented  by  the  infectious  agent  belongs  to  the  group 
which  prefers  a  carbohydrate  to  a  protein  diet.  The  first  proof, 
therefore,  of  pathogenic  microbic  invasion  is  found  by  the  absence 
of  this  copper-reducing  body  from  the  cerebrospinal  fluid.  This  is 
practically  true  in  all  forms  of  brain  inflammation  except  in  the 
tuberculous  variety  of  slow  development.  A  copper-reducing  body 
is  absent  from  the  cerebrospinal  fluid  in  other  forms  of  meningitis. 
This  finding  antedates  by  some  hours,  and  possibly  by  a  longer  period 
than  this,  the  demonstration  of  bacteria  in  the  fluid.  It  is,  therefore, 
of  assistance  in  diagnosing  the  presence  of  a  meningitis  in  its  very 
earliest  stages.  Moreover,  if  the  hydrocephalus  is  due  to  a  previously 
existing  meningitis,  the  reappearance  of  the  copper-reducing  body 
after  its  earlier  disappearance  is  evidence  of  the  subsidence  of  the 
meningitis  and  consequent  improvement  in  the  prognosis.  In  a  fair 
proportion  of  cases  hydrocephalus  seems  to  be  the  result  of  a  chronic 
inflammation  of  the  ependyma. 

A  rachitic  head  is  about  the  only  condition  which  resembles  hydro- 
cephalus. In  rachitis  the  head  is  square,  and  the  vault  is  more  flat 
than  in  hydrocephalus,  where  it  is  apt  to  be  rounded.  The  rachitic 
head  does  not  show  bulging  fontanelles;  moreover,  other  evidences  of 
rickets  are  usually  found  in  the  bones  of  the  chest  or  extremities. 
Systematic  head  measurements  will,  if  the  case  is  hydrocephalus, 
generally  show  a  gradual  increase  in  its  circumference. 

Prognosis. — The  child  usually  becomes  progressively  weaker,  suffers 
from  headache,  vomiting,  and  may  possibly  have  convulsions.  Death 
in  the  large  majority  of  cases  results  from  some  intercurrent  disease. 
The  child  may  die  as  early  as  the  sixth  month,  and  it  rarely  lives  to 
be  more  than  seven  or  eight  years  of  age.  Cure  has  apparently 
taken  place  in  a  few  cases  by  spontaneous  evacuation  through  a 
fissure  into  the  nasal  cavity.  Permanent  drainage  of  the  lateral 
ventricles  seems  to  offer  the  best  prospect  of  cure  in  well-marked 
chronic  cases. 

The  prognosis  as  to  life  depends  largely  upon  the  rapidity  with  which 
the  fluid  accumulates.  In  those  cases  in  which  the  fluid  rapidly 
increases  in  amount,  death  may  occur  at  six  months  or  one  }'ear  with 
all  the  symptoms  of  hydrocephalus  present  in  severe  form.  If, 
however,  the  fluid  accumulates  very  slowly,  there  may  be  few,  if  any, 
symptoms  and  the  prognosis  as  to  life  is  much  better,  the  child  living 
to  be  six  or  eight  years  of  age.  Few  cases  that  show  a  progressive 
enlargement  of  the  head  live  beyond  this  period.  If  the  fluid  ceases 
to  accumulate  at  any  age  life  may  be  indefinitely  prolonged,  the  child 
being  usually  more  or  less  mentally  and  physically  defective. 

Treatment. — In  some  of  my  cases  in  infants  a  cure  has  resulted 
when  hydrocephalus  has  been  associated  with  rachitis,  and  after  one 
or  more  lumbar  punctures  the  infant  has  remained  perfectly  well. 
At  least  three  such  cases  have  now  continued  to  be  well  for  periods 
varying  from  two  to  three  years.     Lumbar  puncture  has  often  in  my 


78  CONGENITAL  MALFORMATIONS 

experience  caused  a  marked  temporary  lessening  in  the  symptoms, 
especially  headache  and  vomiting.  Many  other  operations  have 
been  devised;  fine  drains  or  a  silver  tube  have  been  placed  between 
the  subarachnoid  space  and  ventricles.  This  is  practically  autodrain- 
age,  and  out  of  a  number  of  cases  operated  upon  some  have  shown 
marked  improvement.  The  operation  of  puncturing  the  corpus 
callosum  has  been  employed,  with  the  object  of  relieving  brain  pressure 
by  establishing  an  opening  between  the  ventricles  and  subdural  space 
of  the  brain  cord.  Some  excellent  results  are  reported  to  have  followed 
this  operation.  Permanent  drainage  seems  to  offer  the  greatest  hope 
for  the  permanent  cure  of  this  condition.  Treatment  by  drainage  of  the 
cisterna  magna,  as  recommended  by  Kopetzky  and  Haines,  especially 
for  meningitis,  is  of  course  applicable  to  cases  of  hydrocephalus. 
Better  results  from  operation  are  obtained  in  those  cases  where  the 
accumulation  of  fluid  is  very  slight  than  in  those  where  it  increases 
rapidly  in  quantity.  If  there  is  even  a  vague  suspicion  of  syphilis 
being  the  cause  of  the  condition,  the  child  should  be  given  a  thorough 
course  of  iodide  of  potassium  and  mercury  b}:  inunction.  Fresh  air, 
proper  food,  and  the  best  hygienic  surroundings  possible  assist  in 
keeping  up  the  general  health  and  nutrition. 

Caput  Succedaneum. — The  most  common  malformation  is  the 
swelling  of  that  portion  of  the  head  which  represents  the  presenting 
part.  It  consists  of  an  effusion  into  the  soft  tissues  of  the  scalp  outside 
the  periosteum.  It  is  rarely  seen  following  a  rapid  or  easy  labor,  but 
the  more  tedious  and  prolonged  the  labor  the  more  marked,  as  a  rule, 
is  the  caput  succedaneum.  Its^most  common  location  is  on  one  of  the 
parietal  bones  extending  backward  to  the  occiput.  The  effusion  is 
absorbed  spontaneously,  and  requires  no  treatment.  Care  should  be 
taken  carefully  to  cleanse  the  portion  of  scalp  tissue  overlying  the 
swelling,  and  to  protect  this  portion  from  any  infection  which  might 
follow  slight  trauma  of  the  scalp  occurring  during  labor. 

Cephalhematoma. — Cephalhematoma  is  a  tumor  filled  with  blood, 
produced  by  a  rupture  either  before  birth  or  during  labor  of  some  of 
the  vessels  of  the  cranial  periosteum.  It  is  most  often  found  over 
one  of  the  parietal  bones,  and  is  usually  spontaneously  absorbed. 
It  is  commonly  found  outside  of  the  skull,  although  it  is  occasionally 
situated  inside  the  cranium.  The  variety  outside  of  the  skull  is  called 
external,  and  the  form  within  internal;  the  external  is  by  far  the  more 
common.  In  the  external  variety  the  blood  is  between  the  periosteum 
and  the  skull,  or  between  the  periosteum  and  the  occipitofrontalis 
muscle;  in  the  internal  form  the  extravasation  takes  place  between 
the  dura  mater  and  the  skull. 

Etiology. — A  common  cause  of  cephalhematoma  is  diflBcult  and  pro- 
longed labor,  and  it  may  also  follow  the  application  of  the  forceps. 
It  is  most  common  in  vertex  presentations,  although  occasionally 
observed  in  breech  cases.  Poorly  developed  bloodvessels  and  abnormal 
conditions  of  the  blood  in  infants  are  predisposing  causes.  Another 
predisposing  cause  is  a  weakened  or  badly  nourished  state  in  the  mother. 


BRAIN  AND  SPINAL   CORD 


79 


While  it  is  true  that  difficult  labor  and  the  application  of  the 
forceps  have  much  to  do  with  the  formation  of  cephalhematomata, 
still  the  factors  of  bloodvessels,  blood,  and  nutrition  are  also  operative. 
In  proof  of  this  may  be  mentioned  the  fact  that  cephalhematoma 
has  been  recorded  in  infants  delivered  by  Cesarean  section  and  also 
in  prematurely  born,  hence  small  infants.  It  is  present  in  about  one 
and  a  half  per  cent,  of  all  cases. 

Pathology. — It  is  commonly  found  over  one  of  the  parietal  bones, 
its  position  usually  depending  upon  the  portion  of  the  head  that 
presents,  although  breech  presentations  may  show  the  tumor  in  the 
occipital  region.  One,  two,  or  three  tumors  may  be  found  in  the  same 
patient.    As  the  hemorrhage  is  from  the  periosteum  the  swelling,  on 


Fig.  7. — Double  cephalhematoma  in  an  albino,  aged  three  weeks. 


account  of  the  close  attachment  of  the  periosteum  at  the  sutures,  is 
always  limited  to  the  area  represented  by  the  bone.  Slight  hemor- 
rhage occurs  in  the  scalp.  Beneath  the  cephalhematoma  is  felt  a 
crater-like  opening  which  upon  pressure  at  the  external  border  gives 
a  sensation  of  crackling,  this  crepitus  evidently  resulting  from  pressure 
upon  the  bony  cells  and  the  thin  blood-clots  which  rapidly  develop 
along  the  edges  of  the  tumor;  that  is,  at  the  line  of  separation  of  the 
periosteum.  In  cases  of  cephalhematoma  complicating  severe  injury 
to  the  head,  trauma  of  the  soft  parts,  or  depressed  fractures,  infection 
may  be  present,  and  possibly  meningitis.  The  tumor  usually  entirely 
disappears  in  from  five  weeks  to  three  months,  and  the  smaller  the 
mass  the  more  rapidly,  as  a  rule,  it  is  absorbed.     After  its  absorption, 


80  CONGENITAL  MALFORMATIONS 

a  firm  irregular  thickening  usually  remains  for  a  considerable  length 
of  time  at  the  site  of  the  tumor. 

Symptoms. — A  cephalhematoma  usually  appears  during  the  first 
five  days  of  life,  and  gradually  increases  in  size  for  a  period  of  from 
six  to  ten  days,  then  tends  to  become  smaller.  It  may  vary  in  size 
from  the  smallest  swelling  to  one  as  large  as  a  goose  egg.  Fluctuation 
is  present,  but  the  mass  can  not  be  reduced  in  size  by  pressure,  since 
no  portion  of  it  can  be  returned  within  the  skull.  Violent  crying 
produces  no  effect  on  its  dimensions  or  tenseness,  and  it  is  soft  and 
elastic  to  the  touch.  Unless  infection  has  occurred,  there  are  no  local 
or  constant  signs  of  inflammation,  and  pulsation  is  very  rarely  present. 

Diagnosis. — Cephalhematoma  may  be  diagnosed  from  hernise 
cerebri  by  the  fact  that  the  latter  always  occur  along  one  of  the  suture 
lines,  at  a  f ontanelle,  or  at  some  opening  in  the  skull ;  whereas  cephal- 
hematoma beginning  beneath  the  periosteum  is  always  limited  to 
the  area  of  the  bone.  Meningocele  and  encephalocele  are  partially 
reducible,  and  symptoms  of  cerebral  pressure  commonly  follow  efforts 
at  reduction;  in  addition  to  this,  crying  may  increase  their  size.  None 
of  these  conditions,  of  course,  prevails  in  cephalhematoma.  A 
depressed  fracture  does  not  show  a  tumor  above  the  normal  cranial 
vault  as  does  a  cephalhematoma,  and  the  ridge  that  surrounds  a 
cephalhematoma  is  elevated  above  the  level  of  the  surrounding  bone, 
and  has  a  crater-like  center;  caput  succedaneum  is  not  limited  by 
sutures,  and  is  rapidly  absorbed  within  a  few  days;  moreover,  it  is 
usually  present  at  birth,  while  cephalhematoma  generally  develops 
after  birth.  If  it  is  absolutely  necessary  to  verify  the  diagnosis  of 
cephalhematoma,  an  aspiration  needle  may  be  inserted  into  the 
tumor,  and  the  presence  of  pure  blood  be  demonstrated,  but  this  punc- 
ture, must  be  performed  only  under  the  most  rigid  rules  of  antisepsis. 

Prognosis. — The  prognosis  is  favorable,  absorption  usually  taking 
place  in  from  six  weeks  to  three  months.  If  a  large  hematoma  has 
formed  within  the  skull,  it  may,  unless  rapidly  absorbed,  produce 
pressure  symptoms  and  lesions. 

Treatment. — Uncomplicated  cases  require,  as  a  rule,  neither  local 
nor  constitutional  treatment.  Care  must  be  exercised  that  the  tumor 
be  not  injured  by  pressure  or  manipulation,  and  that  the  scalp  is  kept 
clean  and  free  from  possible  infection.  Any  local  injury  or  infection 
of  the  soft  parts,  bones,  brain  membranes,  or  brain  substance  would 
necessitate  appropriate  surgical  treatment.  An  internal  cephalhema- 
toma producing  symptoms  which  persist  calls  for  surgical  interference. 
Under  strict  antisepsis  a  small  incision  may  be  made  in  the  scalp, 
the  sac  opened,  the  blood  expressed,  and  an  antiseptic  pad  firmly 
applied.  This  has  the  advantage  of  securing  the  immediate  removal 
of  the  blood,  and  prevents  the  thickening  that  may  persist  after 
absorption  without  operation. 

Anencephalia. — Anencephalia  means,  literally,  absence  of  brain; 
and  the  monsters  to  whose  condition  this  term  is  applied  are  born 
with  the  vault  of  the  craniinn  missing,  owing,  it  is  believed,  to  the 


BRAIN  AND  SPINAL  CORD 


81 


production  of  an  abnormally  sharp  cranial  flexure  in  the  embryo. 
Usually  a  reddish,  fleshy  mass,  which  may  contain  rudimentary  brain 


V\r,.  S. — Anencephalia. 


Fig.  9. — Anencephalia. 

tissue,  is  found  lying  upon  the  basal  bones.    In  very  rare  cases  there 
is  no  brain  tissue  whatsoever  (Figs.  8  and  9). 
6 


82 


CONGE NI TAL  MALFORMA  TIONS 


These  fetuses  are  usually  of  the  female  sex.  Their  bodies  are  well- 
developed.  The  head  appears  to  sink  down  between  the  well-formed 
shoulders,  while  the  face  is  turned  upward;  the  eyes  are  protruding. 
The  base  of  the  skull  is  narrow,  the  nose  broad  and  flat,  and  the  mouth 
is  held  partly  open,  which  gives  the  monster  a  toad-like  appearance. 

During  the  last  few  weeks  of  pregnancy  the  pressure  of  the  anen- 
cephalic  head  not  infrequently  causes  extreme  irritability  of  the 
bladder  in  the  mother,  and  at  delivery  the  broad  shoulders  may 
render  podalic  version  necessar}-.    The  face  usually  presents. 

These  monsters  rarely  go  on  to  full  term.  They  are  not  extremely 
rare,  and  most  physicians  with  a  large  obstetric  practice  can  recall 
at  least  one  case  within  their  own  experience.  Formerly  several 
classes  of  these  monsters  were  recognized;  but  today  they  are  all 
included  in  the  term  anencephalia. 


Fig.  lO.^Hare-lip  and  cleft  palate  in  a  infant  five  months  old. 


HARE-LIP  AND  CLEFT  PALATE. 

Hare -lip. — It  is  a  well-known  anatomical  fact  that  congenital 
malformations  of  this  type  are  physiological  at  one  period  in  the 
development  of  the  fetus,  and  are  the  remains  of  fissures  that  are 
primitive  and  naturally  present  in  the  normal  infant  at  a  certain  stage 
of  the  process  of  development. 

Etiology. — ^jNIany  theories  have  been  advanced  as  to  the  causation 
of  these  conditions.  Alcoholism  in  the  parents,  producing  a  lack  of 
developmental  power  in  the  fetus,  is  a  probable  cause,  this  lack  being 
either  mechanical  or  pathological.  Heredity  undoubtedly  plays  an 
important  role,  and  is  by  many  considered  a  most  important  factor. 
An  increase  of  intracranial  pressure,  adhesions,  deficient  amniotic 
fluid,  and  amniotic  bands,  are  also  probable  causes.  A  failm"e  of  the 
globular  processes  to  join  will  also  produce  a  fissure  in  the  upper  lip. 
The  second  upper  maxillary  processes  uniting  with  the  anterior  margins 
of  the  head  fold  form  later  the  upper  maxillary  bone,  and  a  portion  of 


HA  RE -LIP  AND   CLEFT  PALATE 


83 


the  head  fold  also  assists  in  the  formation  of  the  nose  and  intermaxillary 
bone.  The  failure  of  any  of  these  structures  to  develop  properly,  or 
the  lack  of  proper  union  of  these  different  structures,  will  cause  the 
congenital  malformation  of  hare-lip. 

Pathological  Anatomy. — The  fissure  may  be  of  the  lip  only,  and  either 
one  or  both  sides  may  be  involved.  The  deeper  soft  parts,  that  is, 
the  upper  maxillary  processes,  may  or  may  not  be  involved,  and  the 
palate  may  be  normal  or  cleft.  It  may  extend  into  the  nose,  or  may  be 
merel}^  the  slightest  drawing  in  of  the  lip.  The  fissure  is  rarely  if  ever 
in  the  median  line,  and  the  cleft  may  be  large  or  small.  Either  single 
or  double  hare-lip  may  be  associated  with  cleft  palate,  although  double 
hare-lip  with  cleft  palate  is  the  more  common.  ,.  —  , 

The  fissure  is  situated  either  between  the  canine 
tooth  and  the  second  incisor,  or  between  the 
first  and  second  incisors.  The  altered  position  of 
the  intermaxillary  bone  may  cause  the  teeth  to 
develop  at  a  right  angle  to  the  fissure,  or  the 
teeth  may  be  directed  almost  straight  outward. 

Symptoms. — These  infants  often  have  great 
difficulty  in  nursing,  as  it  is  frequently  almost 
impossible  for  them  to  produce  a  partial  vacuum 
in  the  mouth,  hence  they  are  unable  to  cause  the 
milk  to  flow  from  the  nipple ;  moreover,  the  milk 
is  hard  to  swallow  as  it  tends  to  regurgitate 
through  the  fissure  in  the  lip.  Pumping  the 
breasts  and  feeding  with  a  Breck  feeder  (Fig. 
11)  or  a  spoon  is  often  resorted  to.  Every  effort 
should  be  made  to  preserve  the  mother's  milk, 
as  it  is  important  for  the  child  to  be  kept  as 
well-nourished  as  possible.  All  cases,  of  course, 
breathe  largely  through  the  mouth,  which  predis- 
poses them  to  disease  of  the  respiratory  tract. 
Gastro-intestinal  disturbances  and  bronchopneu- 
monia have  also  in  my  experience  been  among 
the  most  common  complications  met  with  in  the 
postoperative  medical  treatment. 

Prognosis. — The  disfigurement  associated  with  a  hare-lip  is  so  marked 
that  almost  all  parents,  even  the  most  ignorant,  will  give  their  consent 
to  an  operation.  The  risk  of  the  infant's  losing  its  life  is  not  great, 
the  mortality  of  the  operation  being  only  about  3  per  cent,  or  less. 

Treatment. — Long  before  the  days  of  antiseptic  surgery,  hare-lip  was 
a  common  condition  upon  which  to  operate ;  the  dangers  of  the  opera- 
tion are  hemorrhage,  infection  which  is  traumatic  in  character,  and 
shock,  the  latter  especially  in  a  frail  young  infant.  The  time  when 
the  infant  should  be  operated  upon  depends  upon  the  general  physical 
condition  and  vitality.  Here,  as  in  all  other  conditions  in  children, 
the  vitality  is  in  proportion  to  the  weight,  general  physical  develop- 
ment, and  constitution.     The  age  of  the  child  is  less  important,  as 


f- 

—  If 

,  ] 

-21 

N"" 

-3| 

■0- 

-% 

:       - 

-5: 

'  ■ 

-^i 

:■ 

— 4} 

Fig.    11.  - 
feeder. 


The   Breck 

(Kirley.) 


84 


CONGENITAL  MALFORMATIONS 


regards  the  time  of  operation,  than  its  physical  condition.  K  vigorous 
child  two  months  of  age  may  be  operated  upon;  a  delicate  infant  of 
two  months  should,  if  possible,  be  built  up  physically,  and  perhaps 
not  be  operated  upon  until  it  is  six  months  old.  Before  operating  the 
child  should  be  carefully  examined  for  other  congenital  malformations, 
especially  of  the  heart,  which,  if  present,  would  naturally  necessitate 
the  postponement  of  operative  measures.  Xasal  catarrh  and  bronchitis 
should  be  cured  by  appropriate  treatment  before  operation,  and 
surgeons  should  insist  on  the  child's  feeding  and  nutrition  being 
looked  after  before  and  after  operation  by  a  skilled  pediatrician. 
Secondary  operations  should  be  deferred  for  at  least  a  few  months. 
For  details  as  regards  the  operation  surgical  treatises  should  be 
consulted. 


Fig.   12.— Hare-lip. 


Cleft  Palate. — Etiology. — ^Yhat  has  been  said  in  regard  to  the 
etiology  of  hare-lip  applies  largely  to  cleft  palate.  Cleft  palate  may 
be  single  or  double.  The  fissure  may  involve  only  the  soft  palate  and 
uvula,  and  this  is  the  most  common  form,  it  may  involve  more  or  less 
of  the  hard  palate,  or,  in  rare  cases,  the  palate  alone.  It  may  or  may 
not  be  associated  with  hare-lip. 

Pathological  Anatomy.^Deformity  results  from  the  failure  of  perfect 
fusion  between  the  hard  palate  and  the  intermaxillary  bone,  as  well  as 
imperfect  union  of  the  vomer  and  the  velum. 

Symptoms. — The  child  has  marked  difficulty  in  both  nursing  and 
swallowing,  as  the  milk  may  regurgitate  through  the  nose.  The  infant, 
breathing,  as  it  does,  through  the  mouth,  is  exposed  to  the  danger  of 
infection  of  the  nose,  throat,  and  lungs.  Speech  is  always  impaired; 
the  voice  has  a  nasal  tone,  and  many  of  the  consonants  are  imperfectly 
articulated.     Owing   to   the   mechanical   difficulty   in   feeding   these 


CONGENITAL   MALFORMATIONS  OF   THE    TONGUE  85 

children,  tJiey  are  often  siiiall,  ill-nourished,  and  delieate,  and  their 
nutrition  and  general  eare  beeome  a  matter  of  the  first  importance. 
It  is  absolutely  necessary  that  the  nasal  pharynx  be  kept  clean,  yet 
care  must  be  taken  never  to  exert  more  than  the  minimum  amount  of 
force,  since  these  mucous  membranes  are  easily  injured  mechanically. 
They  are  also  especially  liable  to  be  affected  with  thrush,  which  may  be 
a  serious  complication,  particularly  if  the  child  is  weak  and  frail.  A 
weak  alkaline  and  mildly  antiseptic  wash  may  be  employed  to  keep  the 
nasal  pharynx  clean,  especially  before  and  after  feeding. 

Prognosis. — The  prognosis  depends,  as  does  that  of  hare-lip,  on  the 
physical  condition  of  the  child.  The  mortality  from  the  operation  is 
3  per  cent. 

Treatment. — Many  surgeons  prefer  to  operate  as  soon  after  the 
thirteenth  or  fourteenth  month  as  the  child's  physical  condition  will 
permit,  and  the  operation  should  always  be  performed  before  the 
beginning  of  the  third  year.  If  a  large  fissure  remains  after  the  first 
attempt  at  closure,  a  second  operation  is  indicated;  but  a  small  fissure 
can  often  be  closed  by  local  applications.  It  is  claimed  that,  if  possible, 
the  repair  of  a  cleft  palate  should  be  accomplished  before  the  period 
when  the  child  ordinarily  begins  to  talk,  and  that,  as  a  result  of  this, 
systematic  exercises  directed  toward  improvement  of  the  speech  are 
a  valuable  aid  which  should,  moreover,  be  begun  before  bad  habits 
of  speech  are  formed.  On  the  same  principle,  it  is  important  that 
everything  possible  should  be  done  to  improve  the  general  health 
and  nutrition  of  the  child,  both  before  and  after  operation.  Breast 
milk  is,  of  course,  the  best  food  for  these  infants,  and  it  may  be 
necessary  to  feed  them  with  a  spoon,  medicine  dropper,  or  a  Breck 
feeder.  An  admirable  arrangement  consists  in  attaching  to  the  ordinary 
nursing  nipple  a  flap  which  more  or  less  perfectly  fits  the  roof  of  the 
mouth  and  assists,  partially  at  least,  in  closing  the  fissure. 

During  the  period  of  residence  in  the  hospital,  both  before  and 
subsequent  to  operation,  gavage  is  of  advantage,  since  by  this  method 
a  larger  amount  of  food  can  often  be  introduced  into  the  stomach. 
After  leaving  the  hospital  it  is  applicable  only  to  those  cases  where  a 
trained  nurse  is  in  attendance. 

CONGENITAL  MALFORMATIONS  OF  THE  TONGUE. 

Tongue-tie. — This  condition  consists  in  a  shortening  of  the  frenum 
of  the  tongue  to  such  an  extent  as  to  render  the  protrusion  of  the 
tongue  beyond  the  lips  difficult,  and  it  is  also  bound  down  to  the 
floor  of  the  mouth  by  the  unnaturally  tight  and  short  frenum.  Articu- 
lation may  be  more  or  less  interfered  with,  and  sucking  may  be 
imperfect.  It  is  a  common  experience  with  all  physicians  to  be  con- 
sulted in  regard  to  children  two  or  three  years  of  age  who  are  supposed 
by  their  parents  to  be  tongue-tied  because  they  do  not  talk.  In  the 
large  majority  of  such  cases,  the  failure  to  talk  is  not  in  any  way 
connected  with  the  tongue,  but  is  significant  of  some  mental  condition 


86  CONGENITAL  MALFORMATIONS 

or  (leaf  inutism.  The  treatiui'iit  of  toiigiu'-tic  is  simply  the  elevation 
of  the  tongue  by  passing  the  slit  oi  a  groove  director  over  the  freniim, 
and  nicking  the  frenum  slightly  with  a  pair  of  blunt  scissors.  If  the 
cut  is  made  close  to  the  gum  the  artery  is  easily  avoided. 

Macroglossia. — Macroglossia,  giant  tongue,  or  hypertrophy  of  the 
tongue,  is  usually  a  symptom  of  some  general  pathological  condition 
such  as  cretinism,  idiocy,  mongoHsm,  and  acromegaly.  In  softie 
patients,  however,  it  may  be  due  to  a  more  or  less  advanced 
hemangioma  or  lymphangioma  of  the  tongue,  according  to  whether  the 
cavities  of  the  tongue  show  enlarged  bloodvessel  involvement  or 
enlarged  lymphatics.  This  condition  is  usually  progressive,  the  tongue 
steadily  growing  larger  until  finally,  owing  to  its  great  size,  it  protrudes 
more  or  less  from  the  mouth,  and  plainly  shows  the  marks  made  by  the 
pressure  of  the  teeth.  It  may  become  so  large  that  swallowing  and 
even  respiration  are  interfered  with.  A  few  cases  are  on  record  where 
increase  in  size  has  been  the  result  of  hypertroph}^  of  the  muscular  fibers. 

Thyroid  extract  is,  of  course,  the  proper  treatment  in  cases  due  to 
cretinism.  In  other  conditions  the  size  has  been  reduced  by  the 
thermocautery  or  excision.  If  the  entire  tongue  is  involved,  portions 
of  the  growth  may  be  removed  by  successive  operations.  On  account 
of  the  danger  of  hemorrhage,  the  lingual  arteries  should  be  ligated 
before  operation. 

Ranula. — A  ranula  is  situated  beneath  the  tongue,  and  is  caused 
by  the  duct  of  the  sublingual  glands  or  of  the  mucous  glands  becoming 
occluded.  The  secretions  of  these  glands  are  consequently  retained, 
and  the  cyst  or  ranula  develops.  As  the  cyst  increases  in  size  it  causes 
a  protrusion  or  swelling  of  the  mucous  membrane  beneath  the  tongue, 
which  is  gradually  lifted  and  pushed  upward.  The  swelling  presents  a 
bluish  appearance,  is  translucent,  painless,  and  gives  a  feeling  of 
fluctuation.  It  contains  a  thick,  viscid,  colorless  fluid.  The  cure  of  the 
ranula  is  best  accomplished  by  its  total  extirpation,  although  it  may 
often  be  brought  about  by  cutting  out  as  large  a  portion  as  possible  of 
the  anterior  wall,  and  touching  up  the  interior  of  the  sac  with  tincture 
of  iodine  or  nitrate  of  silver,  five  grains  to  the  ounce.  Simple  incision 
and  evacuation  of  the  sac  is  not  to  be  recommended;  such  an  incision, 
as  a  rule,  rapidly  heals  and  the  sac  refills. 

CONGENITAL  DISEASES  OF  THE  NECK. 

Fistulae  of  the  Neck. — Etiology. — The  incomplete  fusion  of  certain 
primitive  or  embryonic  structures  results  in  these  malformations. 
Lateral  fissures  are  the  result  of  imperfect  development  in  the  branchial 
clefts,  and  a  median  fissure  is  associated  with  imperfect  development 
of  the  median  lobe  of  the  thyroid.  Heredity,  alcoholism,  and  amniotic 
bands  are  operative  here  as  causative  agents,  just  as  they  are  in  hare-lip 
and  cleft  palate. 

Sjrmptoms. — At  the  middle  or  along  the  sides  of  the  neck  small 
fistulfe  are  occasionally  found  which  exude,  normally  or  under  pressure, 


CONGENITAL  DISEASES  OF   THE  NECK  87 

a  whitish  Uquid.  Tlie  hiterul  fissure  may  end  in  a  cul-de-sae,  or  open 
internally  in  the  neighborhood  of  the  tonsil.  The  external  opening 
coincides  with  the  anterior  margin  of  the  sternocleidomastoid  muscle. 
The  fistulse  in  the  middle  line  of  the  neck,  if  not  blind,  open  under  the 
tongue. 

Treatment. — The  treatment  consists  in  the  total  extirpation  of  the 
fistulse  and  the  cyst,  as  experience  has  shown  that  any  operation  or 
treatment  other  than  this  is  useless. 

Congenital  Cystic  Lymphangioma  of  the  Neck. — Pathological  Anat- 
omy.— ^This  malformation  is  composed  of  dilated  lymphatic  vessels, 
which  become  cysts,  and  adhere  closely  to  the  neighboring  skin, 
muscles,  and  bloodvessels,  the  tumor  usually  increasing  rapidly  in  si^e. 

Symptoms. — The  tumor  develops  in  the  side  of  the  neck,  and  is 
composed  of  many  cysts.  It  tends  to  grow  downw^ard  below  the 
clavicle,  and  may  even  penetrate  into  the  deep  tissues  of  the  larynx 
and  esophagus.  As  the  tumor  becomes  larger,  difficulty  in  swallowing 
and  oppression  in  breathing  develop,  which  become  more  marked  as 
the  pressure  from  the  enlarging  mass  increases. 

Prognosis. — The  prognosis  is  unfavorable  as,  unless  the  diagnosis  is 
made  early  and  the  tumor  completely  removed,  recurrence  is  likely. 

Treatment. — Its  complete  extirpation  is  ahvays  rendered  difficult 
on  account  of  its  close  adhesion  to  all  neighboring  structures;  but 
only  radical  extirpation  will  bring  about  a  cure,  and  it  is  therefore  most 
important  that  the  diagnosis  be  made  early,  since,  owing  to  the  rapid 
growth  of  these  tumors,  the  difficulties  and  dangers  attending  radical 
operations  increase  wdth  any  delay.  If  the  operation  be  only  partial 
or  incomplete,  it  will  be  followed  by  relapse  and  the  continued  new 
growth  of  the  mass.  As  there  is  no  communication  between  the  cysts, 
their  formation  being  much  like  that  of  a  bunch  of  grapes,  puncture 
accomplishes  little. 

Congenital  Torticollis. — Etiology. — Heredity  is  undoubtedly  a  factor, 
as  are  also  intra-uterine  inflammations  and  adhesions.  A  traumatic 
injury  to  the  sternocleidomastoid  muscle  during  delivery  may  be 
followed  by  slow  interstitial  inflammation  in  the  muscle  tissue,  the 
contraction  resulting  therefrom  producing  the  typical  deformity. 

Symptoms. — The  position  of  the  head  is  caused  by  the  contraction 
of  ■  the  affected  sternocleidomastoid  muscle.  The  head  is  rotated 
toward  the  unaffected  side,  and  deflected  toward  the  diseased  side, 
.and  is  held  fixed  in  this  position.  The  sternal  portion  of  the  muscle 
produces  the  rotation  of  the  head,  and  the  clavicular  the  deflection. 

Diagnosis. — The  muscle  can  be  felt  as  a  firm  hard  band.  It  should 
be  remembered  that  diseases  of  the  upper  cervical  vertebrae  and 
occipital  periostitis  are  capable  of  producing  torticollis,  and  that 
the  diagnosis  of  tuberculosis  in  this  upper  spinal  region  can  be  often 
corroborated  by  x-ray  plates. 

Treatment. — The  treatment  of  congenital  torticollis  is  operative; 
either  open  section  or  partial  extirpation  of  the  diseased  muscle  is  the 
operation  of  choice.     Open  section  of  the  muscles  is  to  be  preferred 


88  CONGENITAL  MALFORMATIONS 

to  subcutaiieoiis  section  as  l)eiiig'  more  thorougli  and  less  a])t  to  injure 
the  large  bloodvessels.  The  lower  portion  of  the  muscle,  dividing 
as  it  does  into  two  parts,  is  the  place  of  election  for  operation.  The 
spinal  accessory  nerve  is  in  this  region,  and  care  must  be  taken  to 
avoid  injuring  it.  After  operation  the  head  is  fixed  by  pads  and 
bandages  in  a  position  of  overextension.  If  any  scoliosis  has  developed 
as  a  result  of  the  torticollis,  it  must  receive  appropriate  treatment.  It 
seems  almost  unnecessary  to  urge  the  necessity  of  early  operation 
in  congenital  torticollis.  During  the  first  few  weeks  of  life  a  pad  may 
be  worn  and  daily  massage  employed,  and  if,  at  the  age  of  three  months, 
there  is  not  distinct  improvement  an  operation  should  be  performed. 
Firm  and  fixed  scoliosis  has  not  occurred  at  this  period,  and  the  sub- 
sequent result  is  better  and  treatment  is  simpler  if  the  operation  is 
performed  at  this  early  age.  Torticollis  is  often  only  a  symptom,  and 
in  these  cases  it  is  necessary  to  treat  the  underlying  cause  as  well  as  the 
torticollis. 

CONGENITAL  MALFORMATIONS  OF  THE  ESOPHAGUS. 

Congenital  malformations  of  the  esophagus  include  absence  of  the 
esophagus,  in  whole  or  in  part,  stenosis  of  varying  degree,  dilatation,  a 
bending  or  twisting  of  the  canal,  and  fistulse  communicating  with 
the  trachea. 

Symptoms. — Vomiting  is,  of  course,  the  cardinal  symptom.  If  the 
stenosis  is  of  such  degree. as  to  permit  the  slow  trickling  of  fluids 
through  the  passage,  a  small  amount  of  liquid  nourishment  may  be 
ingested  and  retained;  whereas,  if  a  large  amount  is  given,  a  portion 
of  it  is  always  vomited.  If  solid  or  semisolid  food  blocks  the  small 
aperture  in  the  esophagus,  the  giving  of  such  food  may  be  followed  by 
vomiting  6f  almost  all  nourishment  so  long  as  the  more  solid  material 
continues  to  occlude  the  small  esophageal  opening.  Congenital 
obstruction  is  undoubtedly  much  more  common  than  was  formerly 
supposed,  and  cases  of  persistent  vomiting  in  young  children  should 
be  studied  with  this  possible  diagnosis  in  mind. 

Treatment. — The  treatment  is  most  unsatisfactory.  Stenosis  of 
moderate  degree  has  been  successfully  treated  by  dilatation;  for  the 
oth^r  conditions  gastrostom}"  is  necessary,  after  which  an  attempt 
can  be  made  to  feed  the  child  through  the  artificial  gastric  fistula. 
If  the  infant's  strength  will  permit,  an  effort  may  be  subsequently 
made  to  overcome  the  congenital  defect  by  surgical  measures.  As  the 
operation,  except  in  cases  of  moderate  stenosis,  usually  has  to  be  per- 
formed when  the  infant  is  only  a  few  days  old,  the  risk  attending  it  is 
of  course  very  great.  The  condition  of  cardiospasm  may  be  congenital ; 
it  is  not  a  malformation,  and  can  usually  be  treated  successfully;  still 
it  may  in  early  life  produce  symptoms  identical  with  those  of  organic 
stenosis,  hence  its  existence  should  be  borne  in  mind. 

Meckel's  Diverticulum. — Meckel's  diverticulum  is  a  persistence  of 
the  ductus  omphalomesentericus. 


CONGENITAL  MALFORMATIONS  OF   THE  ESOPHAGUS        S9 

Etiology. — This  duct,  which  iioruially  exists  in  the  fetus  and  connects 
the  intestine  and  the  vitelhne  membrane,  closes  at  about  the  end  of  the 
second  month.  The  canal  or  duct  arises  from  the  lower  portion  of  the 
small  intestine,  about  twelve  inches  above  the  ileocecal  valve.  It  may 
be  a  cul-de-sac  a  few  inches  long,  or  it  may  remain  open  as  far  as  the 
umbilicus,  and  permit  the  passage  of  fecal  matter.  The  mucous 
membrane  of  the  duct  may  prolapse  through  the  umbilicus,  producing 
a  small  tumor.  Instead  of  persisting  as  an  open  or  closed  duct,  this 
congenital  condition  may  exist  as  a  cord  extending  from  the  low^er 
ileum  to  the  umbilicus,  and  a  portion  of  the  bowel  may  be  caught  and 
constricted  by  this  cord,  and  intestinal  obstruction  and  strangulation 
produced.  It  must  be  remembered  that  this  coiidition  is  possible  in 
child  or  adult  life  as  well  as  in  infancy.  In  those  children  in  whom 
the  duct  remains  open  a  discharge  of  mucus  or  feces  w^ill  occur  at 
the  umbilicus.  If  the  umbilical  end  of  the  duct  is  obliterated  a  cyst 
is  formed  at  the  umbilicus.  This  is  reddish,  globular,  and  usually 
contains  a  whitish  secretion.  Occasionally,  if  the  lumen  is  sufficient, 
the  intestine  may  be  drawn  into  this  cyst,  and  intestinal  obstruction 
thus  develop.  A  twisting  of  the  pedicle  of  the  duct  may  lead  to  intes- 
tinal perforation  and  resulting  peritonitis;  an  intestinal  stenosis  from 
the  prolapse  of  the  ductus  into  the  lumen  of  the  intestines  has  been 
observed,  and  intussusception  may  be  produced  by  inversion  of  the 
duct.  Perforation  of  the  diverticulum  with  resulting  peritonitis 
may  be  induced  by  ascarides  in  its  lumen,  or  fecal  impaction,  or  any 
cause  which  may  produce  localized  inflammation  and  necrosis.  Adeno- 
mata may  develop  from  the  tissues  of  the  duct,  and  present  themselves 
as  a  tumor  of  the  umbilicus. 

Symptoms. — Symptoms  of  intestinal  obstruction  or  strangulation 
are  possible  as  a  result  of  Meckel's  diverticulum.  They  may  be  caused 
by  a  prolapse  of  the  diverticulum  into  the  bowel,  or  the  band-like 
cord  which  may  exist,  instead  of  the  more  or  less  patulous  duct, 
may  cause  a  sufficiently  tight  constriction  of  a  loop  of  intestine  to 
produce  strangulation. 

Diagnosis. — The  presence  of  a  fecal  discharge  at  the  umbilicus  is 
strongly  suggestive  of  Meckel's  diverticulum.  In  a  fistula  of  the 
urachus,  the  direction  of  the  fistula  is  toward  the  bladder,  and  the 
reaction  of  the  discharge  is  acid.  A  fistula  of  the  urachus  is  also  indi- 
cated if  any  of  the  normal  ingredients  of  urine  can  be  demonstrated 
in  the  discharge.  An  alkaline  reaction  suggests  a  connection  with 
the  lower  bowel.  If  any  connection  with  the  bladder  exists,  methy- 
lene blue  injected  into  the  fistula  will  later  show  itself  in  the  urine. 
In  fistula  of  the  urachus  prolapse  of  the  mucous  membrane  may 
also  cause  a  tumor  at  the  umbilicus,  but  this  is  comparatively 
rare. 

Prognosis. — It  depends  upon  the  patulous  condition  of  the  duct; 
the  persistence  of  the  duct  as  a  cord  or  band ;  the  presence  of  a  tumor 
at  the  umbilicus  and  the  contents  of  this  tumor;  and  the  healthy 
or  diseased  condition  of  the  walls  of  the  duct. 


90  CONGENITAL  MALFORMATIONS, 

Treatment. — The  reiiKnal  of  the  (h\ erticuhim  is  the  i>roper  treat- 
ment. An  incision  made  along  the  median  line  of  the  rectus  permits 
its  complete  removal  and  the  invagination  of  the  stump.  The  com- 
plication of  tumor  at  the  umbilicus  must,  of  course,  be  treated  surgically. 

HERNIA  OF     THE     UMBILICAL  CORD. 

In  the  development  of  the  fetus  the  intestines  lie  outside  the 
abdominal  walls,  the  closure  of  the  abdomen  being  brought  about  by 
the  fusion  of  two  sides  of  the  abdominal  walls.  In  this  developmental 
process  the  bowel  appears  in  the  umbilical  cord,  and  is  covered  by 
peritoneum,  Wharton's  jelly,  and  amnion. 

Symptoms. — The  tumor  is  usually  of  small  size,  although  occasionally 
it  is  quite  large.  It  contains,  perhaps,  a  loop  of  intestine,  Meckel's 
diverticulum,  or  it  may,  if  of  large  size,  contain  one  or  more  abdominal 
organs,  possibly  the  liver,  spleen,  pancreas,  or  kidney.  The  mass  is 
situated  at  the  umbilicus,  and  the  umbilical  cord  is  a  part  of,  and 
extends  beyond,  the  tumor. 

Prognosis. — The  prognosis  is  fatal  unless  the  condition  is  of  such  a 
nature  that  it  can  be  immediately  relieved  by  operation.  It  is  danger- 
ous to  ligate  these  tumors  without  first  opening  them  and  assuring 
one's  self  that  the  mass  does  not  contain  any  coil  of  intestine.  If  the 
tumor  is  small,  the  method  advised  by  Olshausen  of  making  an  incision 
in  the  healthy  skin  surrounding  the  tumor,  detaching  the  amnion 
from  the  inner  membrane  in  Wharton's  jelly,  reducing  the  hernia, 
and  closing  the  skin  over  it  has  been  practised  with  success.  In  this 
operation  the  peritoneum  is  not  opened.  Large  tumors,  if  containing 
only  intestine,  may  be  operated  upon,  and  at  times  successfully,  by 
opening  the  hernial  sac  and  returning  the  contents  within  the  abdomen. 
If  the  tunaor  contains  any  large  part  of  one  or  more  of  the  abdominal 
organs,  the  operation  is  both  a  dangerous  and  difficult  one,  and  infec- 
tion of  the  peritoneum  frequently  results.  Cases  have  been  reported 
where  the  cautery  has  been  used  successfully  to  remove  the  middle 
lobe  of  the  liver  which  has  been  found  in  the  hernial  sac. 


UMBILICAL  HERNIA. 

Normal  development  causes  the  complete  closure  of  the  abdominal 
walls  with  the  exception  of  that  small  portion  at  the  navel  which 
must  remain  open  in  order  that  the  umbilical  vessels  be  patulous.  As 
the  cord  desiccates  and  is  detached,  this  s'mall  opening  has  a  normal 
tendency  gradually  to  close,  and,  after  the  cord  has  fallen,  the  only 
use  of  the  abdominal  binder  is  to  hold  a  small  compress  over  this  still 
unclosed  umbilicus.  As  the  child  grows  very  rapidly  at  this  period, 
the  tissues  fill  up  this  unclosed  portion,  and  it  soon  becomes  obhterated. 
If  the  infant  is  premature,  frail,  or  badly  nourished,  closure  may  not 
take  place;  this  is  more  common  in  girl  infants.  Severe  crying, 
coughing,  or  marked  abdominal  distention  also  has  a  tendency  to 


UMBILICAL  HEUNIA 


91 


prevent  closure,  as  does  traction  of  tJie  umbilical  cord.  The  co\crii)gs 
of  the  bowel  in  the  hernia  are  skin,  transverse  fascia,  and  peritoneum. 

Symptoms. — This  form  of  hernia  rarely  produces  any  symptoms. 
It  may,  however,  gradually  increase  in  size,  especially  if  constipation, 
cough,  and  much  abdominal  distention  are  present,  and  is  often  much 
increased  later  in  life  by  pregnancy. 

Treatment. — Prophylaxis  embraces  the  wearing  of  a  snug,  but  not 
tight,  abdominal  binder,  with  a  small  retaining  pad  over  the  navel. 
This  should  be  worn  at  least  during  the  first  two  months,  or  longer  if 


Fig.   13. — Adhesive  plaster  applied  for  umbilical  hernia. 


necessarv. 


As  soon  as  the  hernia  is  discovered,  it  should  be  returned 
within  the  abdominal  cavity  and  retained  by  doubling  in  over  the 
umbilicus  two  longitudinal  folds  of  tissue,  one  from  either  side  of  the 
abdominal  wall  and  on  opposite  sides  of  the  umbilicus,  and  retaining 
.these  folds  in  place  with  two  broad  strips  of  zinc  oxide  adhesive  plaster. 
If  properly  applied,  these  strips  will  remain  in  position  for  some  days, 
and  will  produce  very  little  irritation  of  the  skin.  They  should  extend 
from  one  side  of  the  outer  abdominal  wall  across  to  the  other,  that  is, 
about  half  way  around  the  child's  body  (Fig.  13),  and  this  method 


92  COXGEXITAL  MALFORMATIOXS 

of  treatment  should  be  eontinuetl  for  two  or  three  mouths,  or  longer  if 
the  hernia  persists.  It  is  mueh  more  liable  to  result  in  a  cure  than  the 
application  of  the  ordinary  umbilical  truss  with  a  conical  projection 
which  fits  into  the  opening  and  really  tends  to  prevent  its  closure. 
A  flat  object,  such  as  a  coin,  may  be  covered  with  zinc  oxide  plaster, 
and  retained  over  the  umbilical  opening  w^ith  adhesive  strips.  The 
skin  must  always  be  kept  absolutely  sweet  and  clean.  It  is  extremely 
difhcult — in  fact,  almost  impossible — to  retain  in  proper  position 
any  form  of  apparatus  on  a  child  who  has  reached  the  walking  age. 
In  older  children  many  of  these  umbilical  hernise,  if  small,  gradually 
tend  to  close  as  the  child  grows  and  develops,  and  it  has  rarely,  in 
my  experience,  been  necessary  to  resort  to  surgical  treatment.  How- 
ever, if  the  hernia  is  large  and  especially  if,  in  a  girl,  it  tends  to 
enlarge,  a  surgical  operation  is  undoubtedly- the  proper  treatment. 

CONGENITAL  DILATATION  OF  THE  COLON. 

Congenital  dilatation  of  the  colon,  or  Hirschsprung's  disease,  is  a 
rare  congenital  affection. 

Pathological  Anatomy. — The  colon  is  longer  than  normal,  is  con- 
voluted, greatly  dilated,  and  the  muscular  walls  of  the  dilated  portion 
are  usually  much  hypertrophied.  In  some  cases  the  transverse  portion 
of  the  colon  is  affected,  and  in  others  the  descending  portion  of  the 
colon  and  the  sigmoid  flexure.  The  dilatation  produces  constipation, 
and  the  materials  retained  in  the  bowel  undergo  fermentation  and 
decomposition  which  tend  still  further  to  increase  the  dila- 
tation. 

Symptoms. — The  most  marked  symptom  is  constipation,  which  may 
be  present  at  birth,  or,  if  not,  develops  soon  after,  and  is  shortly 
followed  by  abdominal  distention.  The  infant,  and  especially  the  older 
child,  will  often  go  for  a  number  of  days  without  a  stool,  this  constipa- 
tion being  followed  by  a  conservative  diarrhea  which  partially  clears 
out  the  bowel,  the  stool  consisting  of  hard,  lumpy  masses  of  fecal 
matter  and  much  mucus.  Enemata  are  only  fairly  successful  in 
bringing  away  the  retained  fecal  mass,  and  large  doses  of  laxatives 
usually  become  necessary.  The  infant,  and  later  the  child,  is  weak  and 
emaciated,  and  the  contour  of  the  enormously  distended  abdomen  often 
changes  in  a  curious  w^ay  while  it  is  being  examined,  as  a  result  of  the 
gas  moving  from  one  portion  of  the  bowel  to  another,  and  the  coils  of 
enlarged  intestine  can  often  be  outlined  through  the  thin  abdominal 
walls.  iVfter  the  administration  of  purgatives,  large  masses  of  feces 
are  passed  with  much  flatus,  and  the  abdominal  distention  is,  to  a 
slight  extent,  temporarily  lessened.  Intestinal  toxemia  of  more  or  less 
marked  degree  is  often  present,  and  in  most  cases  that  come  to  opera- 
tion or  autopsy  the  mucosa  of  the  bowel  shows  superficial  ulceration. 
A  stricture  below  the  dilatation  has  not  been  observed.  The  child 
becomes  anemic  and  cachectic,  and  in  infants  severe  nervous  symptoms 
are  not  uncommon.    The  exact  size,  shape,  and  location  of  the  colon 


ATRESIA   OF   THE  BOWEL  93 

can  be  absolutely  mapped  out  by  giving  the  child  a  bismuth  meal,  or 
injecting  the  colon  with  bismuth,  and  then  taking  .r-ray  plates. 

Prognosis. — These  infants  are  all  under  weight,  and,  owing  to  their 
poor  physical  condition,  many  of  them  die  of  inanition  or  secondary 
diseases.  If  the  dilatation  is  slight,  they  may  reach  adult  life,  but 
the  majority  of  the  severe  cases  die  in  infancy.  A  number  of  cases 
are  on  record  in  which  the  dilated  colon  has  been  successfully  removed 
by  operation. 

Treatment. — jNIedical  treatment  can,  at  least,  alleviate  the  symptoms, 
and  make  the  child  more  comfortable.  The  most  important  object 
to  be  accomplished  is  to  build  up  as  well  as  possible  the  child's  general 
health.  Fresh  air,  an  easily  digested  and  nourishing  diet,  selecting 
those  foods  that  are  best  adapted  to  the  child's  digestion,  will  help 
to  maintain  bodily  weight  and  vitality.  Daily  irrigation  of  the  colon 
with  two  quarts  of  warm  salt  solution  is  a  valuable  aid  in  overcoming 
the  constipation,  and  tends  to  cleanse,  at  least,  the  lower  portion  of  the 
large  bowel.  A  daily  laxative,  such  as  podophyllin  or  cascara,  is  of 
service,  although  it  is  advisable  to  change  the  laxative  from  time  to 
time,  as  the  child  will  otherwise  require  increasing  doses.  Abdominal 
massage,  especially  over  the  colon,  will  assist  in  promoting  peri- 
stalsis. Give  the  child  plenty  of  water  to  drink,  and  establish  regular 
hours  for  him.  to  go  to  the  toilet.  The  habit  of  placing  small  children 
at  a  certain  hour  each  day  on  the  chamber  is,  in  my  experience,  the 
most  essential  part  of  the  treatment  of  constipation,  no  matter  what 
its  cause.  If  the  above  outlined  medical  treatment  were  instituted 
as  soon  as  the  first  evidences  of  constipation  were  observed,  it  would 
probabl}'^  be  effective  in  a  small  proportion  of  cases.  This  is,  however, 
rarely  possible  except  among  the  most  intelligent  classes,  and  the 
failure  of  the  child  to  gain  in  weight  and  strength,  or  its  progressive 
loss  in  strength,  often  makes  a  surgical  operation  the  only  pro- 
cedure. 

Formerly  an  artificial  anus  was  the  usual  operation,  the  opening 
being  made  in  the  bowel  above  the  dilated  portion.  This  puts  largely 
at  rest  any  portion  of  the  colon  which  is  abnormally  dilated,  and  the 
physiological  rest  enables  it  to  regain  in  part  its  normal  ^dgor  and  tone. 
A  second  operation  is  then  performed  to  close  the  artificial  anus  and 
reestablish  the  normal  passage  of  the  feces  per  rectum.  Recently  the 
tendency  has  been  to  remove  the  dilated  portion  of  the  colon,  and 
while  it  is  a  very  serious  and  radical  operation  it  has,  nevertheless, 
been  performed  successfully  in  a  few  cases.  Some  surgeons  divide 
the  operation  into  two  stages,  in  order  to  lessen  shock.  It  is  to  be 
sincerely  hoped  that  with  advance  in  modern  surgery  this  operation 
will  soon  be  established  on  a  firm  basis. 

ATRESIA  OF  THE  BOWEL. 

The  principal  etiological  factors  are  peritonitis,  volvulus,  and  syph- 
ilis.   Fetal  peritonitis  manifests  itself  by  an  inflammatory  exudation 


9-1  CON  GEN  I TA  L  MA  LFO  RMA  TIONS 

resulting  in  adhesions  formed  between  coils  of  intestine.  Volvulus  is 
the  probable  cause  when  atresia  is  found  in  several  diflferent  portions 
of  the  bowel. 

Location  and  Variety  of  Malformations. — The  most  common  location 
is  at  the  anus.  The  anal  opening  may  be  the  only  part  that  is  defective, 
everything  else  being  normal.  The  normal  anal  opening  may  be 
present,  and  nothing  but  a  delicate  septum  interfere  with  the  normal 
passage  of  feces.  In  other  cases  the  location  of  the  anal  orifice  may 
be  simply  represented  by  a  dimple,  the  rectum  ending  in  a  cul-de-sac. 
This  cul-de-sac  may  be  situated  very  close  to  the  normal  anal  opening, 
or  it  may  be  so  far  removed  from  this  position  that  a  long  and,  perhaps, 
difficult  dissection  may  be  necessary  to  establish  an  anal  opening. 
The  intervening  space  between  the  two  points  of  atresia  of  the  bowel 
may  be  replaced  in  either  the  entire  or  a  portion  of  the  distance  by  a 
fibrous  cord. 

In  another  form  of  malformation,  the  anal  opening  and  adjacent 
portion  of  the  rectum  are  present,  but  end  in  a  cul-de-sac.  The  distal 
portion  of  the  bowel  may  immediately  join  this  cul-de-sac,  being,  per- 
haps, separated  by  only  a  delicate  septum,  or  a  considerable  space 
may  intervene  between  the  two  extremities  of  the  bowel.  The  rectum 
may  open  internally  into  the  bladder,  or  a  fistulous  opening  may  con- 
nect the  rectum  and  bladder;  in  other  cases,  the  rectum  is  connected 
with  the  urethra  or  Avith  the  vaginal  vestibulum. 

Symptoms. — The  symptoms  vary  according  to  the  location  of  the 
obstruction.  If  the  fecal  contents  do  not  escape  through  some  fistulous 
tract,  the  condition  invariably  produces  constipation,  followed  by 
dilatation  of  the  portion  of  the  bowel  immediately  above  the  obstruc- 
tion, and  subsequent  vomiting.  If  the  obstruction  is  in  the  small 
intestine,  especially  if  in  the  upper  portion,  vomiting  is  an  early 
symptom,  and  is  persistent.  The  portion  of  the  bowel  below  the 
obstruction  is  emptied  of  meconium,  and  the  subsequent  stools  contain 
nothing  but  mucus.  These  cases  are  conspicuous  by  the  rapid  loss  of 
flesh,  increasing  asthenia,  and  early  death.  With  the  exception  of  the 
lower  end  of  the  rectum,  the  upper  portion  of  the  small  intestine  is  the 
most  common  seat  of  intestinal  atresia.  If  the  obstruction  is  only 
partial,  the  symptoms  are  less  pronounced,  and  the  child's  life,  unless 
a  surgical  operation  be  performed,  depends  upon  the  amount  of  food 
that  trickles  through  the  constricted  portion.  The  constipation  in 
these  cases  is,  of  course,  in  proportion  to  the  degree  of  stenosis,  which 
limits  the  amount  of  food  that  passes  on  into  the  lower  bowel.  The 
portion  of  the  bowel  above  the  atresia  is  always  distended  and  dilated, 
while  that  below  is  small  in  calibre,  and  generally  poorly  developed. 
If  the  urine  at  any  time  contains  fecal  matter,  a  communication 
between  the  rectum  and  the  bladder  will  be  naturally  suspected. 

Diagnosis. — An  absence  of  the  normal  anal  opening  should  be  dis- 
covered during  the  first  bathing  and  cleansing  of  the  infant;  otherwise, 
there  is  nothing  at  birth  that  would  cause  one  to  suspect  the  malforma- 
-tion.     Vomiting  soon  after  birth  associated  with  constipation  and 


MALPOSITION  OF   THE   DOWEL  95 

abdominal  distention  suggests  an  obstruction  high  up  in  the  small 
bowel,  while  constipation  followed  by  abdominal  distention  and 
vomiting  suggests  an  obstruction  low  down  in  the  bowel.  In  atresia, 
where  the  anal  opening  is  present,  and  a  small  portion  of  the  adjacent 
lower  bowel  also,  a  finger  inserted  in  the  rectum  discloses  the  fact  that 
the  bowel  ends  in  a  cul-de-sac.  If  the  examining  finger  discloses  a 
mass  which  presses  down  against  it  on  crying,  the  amount  of  tissue 
lying  between  the  upper  and  lower  portion  of  the  bowel  may  probably 
be  more  or  less  accurately  estimated. 

The  diagnosis  may  be  confused  by  the  fact  that  the  obstruction  is 
present  at  more  than  one  point,  and  a  bismuth  meal  and  x-T&y  plates 
may  be  of  assistance  in  diagnosing  this  condition.  Possibly  they  may 
assist  in  locating  the  site  of  the  lesion,  particularly  in  those  cases  where 
a  fistula  allows  some  of  the  fecal  matter  to  pass  beyond  the  point  of 
obstruction,  or  may  aid  in  locating  the  several  points  of,  possibly, 
partial  obstruction,  atresia  of  the  bowel  not  being  complete,  but  the 
condition  being  one  of  stenosis..  Injections  of  bismuth  per  anum  may 
also  be  of  advantage  in  those  cases  where  the  lower  portion  of  the 
large  bowel,  extending  upward  from  a  normal  anal  orifice,  ends  in  a 
cul-de-sac. 

Prognosis. — The  infant  at  birth  h^as,  of  course,  little  power  to  endure 
'A  severe  surgical  operation,  and,  except  in  those  cases  where  the 
obstruction  is  situated  near  the  anal  region,  the  condition  is  usually 
fatal.  If,  however,  the  bowel  contents  empty  externally  by  means  of 
a  fistula,  the  prognosis  as  to  life  is  good. 

Treatment. — With  the  exception,  however,  of  such  cases,  all  patients 
will  require  a  surgical  operation  to  effect  a  cure. 

MALPOSITION  OF  THE  BOWEL. 

Malpositions  of  the  bowel  are  now  more  often  recognized  and  under- 
stood, owing  to  the  taking  of  rc-ray  plates  after  bismuth  meals,  but  one 
must  not  be  too  positive  in  regard  to  the  permanent  position  of  any 
particular  portion  of  intestine  after  one  a:-ray  examination.  I  have, 
in  a  number  of  cases,  seen  a;-ray  plates  which  showed  portions  of  the 
bowel  evidently  much  out  of  position  as  a  result  of  an  unnaturally 
long  and  loose  mesentery,  where,  in  a  plate  taken  later,  the  bowel 
had  practically  returned  to  its  normal  position.  A  portion  of  intestine 
situated  temporarily  out  of  its  normal  position,  may  or  may  not  be  the 
cause  of  symptoms,  and  even  if  one  is  reasonably  sure  that  certain 
symptoms  are  the  result  of  the  malposition,  it  is  wiser  in  the  majority 
of  cases  to  avoid,  if  possible,  surgical  interference,  in  the  hope  that  the 
bowel  may  return  to  a  more  normal  position  and  the  symptoms  dis- 
appear. If  the  displaced  portion  of  the  bowel  is  fixed  in  its  new 
position  and  produces  no  alarming  symptoms,  it  should  be  carefully 
watched;  if  the  symptoms  persist  and  are  of  a  sufficiently  severe  type 
to  warrant  it,  surgical  interference  is  indicated. 

The  bowel  may  be  in  malposition  in  a  congenital  umbilical  hernia 


9G  CONGENITAL  MALFORMATIONS  ^ 

which  may  contain  more  or  less  intestine;  also  in  a  diaphragmatic 
hernia  which  may  contain  coils  pushed  through  the  diaphragm  up 
into  the  thorax. 

EXSTROPHY  OF  THE  BLADDER. 

In  these  patients  the  bladder  is  situated  outside  of  the  abdominal 
wall,  and  the  malformation  is  the  result  of  arrested  development 
which  creates  a  fissure  in  the  abdominal  wall.  It  is  by  some  believed 
to  be  the  result  of  the  bursting  of  the  allantois,  caused  by  an  unusual 
amount  of  secretion  before  the  lower  aperture  for  its  escape  had  been 
formed. 


Fig.   14. — Exstrophy  of  the  bladder  and  epispadias  in  a  child  five  months  old. 

Pathological  Anatomy. — The  anterior  part  of  the  abdominal  wall  is 
absent,  and  there  are  often  other  congenital  malformations,  among 
which  is  an  absence  of  union  at  the  symphysis  pubis.  The  fissure  may 
extend  to  the  urethra  with  epispadias,  fissured  scrotum,  and  unde- 
cended  testes  in  the  male,  and  open  urethra  and  fissure  of  the  labia  and 
clitoris  in  the  female. 

Symptoms. — The  mucous  membrane  protrudes  through  a  fissure  in 
the  abdominal  wall;  it  is  of  normal  color,  is  folded  into  ridges,  and 
is  continuous  with  the  skin  of  the  abdomen.  Any  increase  of  intra- 
abdominal pressure  causes  a  still  further  protrusion  of  the  mass.  The 
openings  of  the  ureters  are  situated  in  the  lower  portion  of  the  tumor. 
The  urine  dribbles  continuously,  and  causes  a  most  annoying  irritation 
of  the  skin.  This,  associated  w^ith  the  continual  odor  of  urine,  makes 
all  patients  who  have  arrived  at  an  age  when  they  can  appreciate 
their  condition  only  too  willing  to  submit  to  a  surgical  operation. 


UNDESCENDED   TESTES— C BY PTORCUI DISM 


97 


Prognosis. — Many  of  these  children,  if  unoperated  upon,  die  from 
infection  of  the  bladder  and  kidneys.  A  number  have  been  success- 
fully operated  upon  both  in  child  and  young  adult  life. 

Treatment. — The  treatment  is,  of  course,  purely  surgical;  either  the 
covering  up  of  the  defect  in  the  anterior  wall  with  a  skin  flap  and  the 
formation  of  a  new  urethra,  or  the  implantation  of  the  ureters  into 
the  intestinal  tract,  is  the  operation  now  most  popular.  Very  favor- 
able results  have  followed  the  transplantation  of  the  ureters  into  the 
rectum;  the  patient  develops  a  control  of  the  urine  which  may  last 
for  hours  during  the  day  or  night.  The  results  are  often  so  satisfactory 
that  it  is  wise  to  give  all  cases  the  benefit  of  an  operation. 


Fig.   15. — Exstrophy  of  the  bladder  in  a  child  seven  months  old. 


UNDESCENDED  TESTES;  CRYPTORCHIDISM. 

The  testicles  develop  in  the  abdomen,  and  usually  descend  into  the 
scrotum  in  the  last  few  weeks  of  intra-uterine  life.  It  is  not  uncommon, 
however,  to  find  one  or  even  both  of  them  in  the  abdominal  cavity 
in  an  infant  otherwise  normal  and  healthy  and  born  at  full  term. 
Ordinarily  we  find  that  one  testicle  has  descended  into  the  scrotum 
while  the  other  is  still  retained  in  the  inguinal  canal.  As  a  rule,  it 
descends  in  the  first  few  weeks  of  life,  its  retention  having  produced 
no  symptoms,  and  after  its  descent  the  inguinal  canal  usually  closes 
normally.  It  may  be  retained,  however,  either  within  the  abdominal 
cavity,  or  at  the  entrance,  or  in  some  portion  of  the  inguinal  canal  for 
months  or  years;  occasionally,  possibly  owing  to  its  increased  size 
and  weight,  it  descends  into  the  scrotum.  This  may  occur  at  any  time 
in  the  child's  life  up  to  the  age  of  ten  years.  The  longer  it  remains 
out  of  its  normal  position,  the  less  likelihood  is  there  of  its  descending 
into  the  scrotum.  In  the  inguinal  canal  it  is  exposed  to  traumatism, 
and  as  puberty  approaches  it  is  apt  to  cause  a  nauseating  pain;  often, 
if  out  of  its  normal  position,  it  does  not  develop  properly,  and  an 
7  "    , 


98  CONGENITAL  MALFORMATIONS 

undescended  testicle  is  more  liable  to  become  diseased  than  one  in 
normal  position.  If  it  remains  in  the  canal,  it  predisposes  to 
hernia. 

Diagnosis. — The  absence  of  the  testicle  in  the  scrotum  can  hardly 
escape  the  notice  of  the  mother  or  nurse.  By  passing  the  little  finger 
up  the  inguinal  canal,  the  testicle  can  usually  be  felt  either  in  the 
canal  or  at  the  internal  opening  of  the  abdomen. 

Treatment. — In  a  young  infant  it  is,  in  some  cases,  possible  by  gentle 
manipulation  to  push  the  testicle  downward,  perhaps  into  the  scrotum; 
this  may  assist  in  restoring  the  organ  to  its  normal  position,  and,  if 
performed  gently,  does  no  harm  and  may,  possibly,  do  good.  If  at 
the  age  of  ten  years  the  testicle  has  not  descended,  the  recognized 
operation  of  the  day  is  to  transplant  the  organ  into  the  scrotum,  which 
is  usually  possible  of  accomplishment.  If,  however,  in  any  particular 
case,  this  operation  cannot  be  performed,  it  is  wiser  to  return  the 
organ  into  the  abdominal  cavity.  If  the  testicle  becomes  diseased, 
and  it  is  a  well-known  fact  that  in  its  unnatural  position  it  is  more 
likely  to  undergo  certain  degenerative  changes,  it  should  be  immedi- 
ately removed;  but  its  removal  should  never  be  advised  unless  it  has 
undergone  some  such  change. 

HYDROCELE. 

Hydrocele,  of  which  there  are  several  forms,  is  a  collection  of  fluid 
in  the  tunica  vaginalis,  and  is  a  very  common  condition  in  the  infant. 
It  is  caused  by  a  failure  of  fusion  of  the  pars  vaginalis  of  the  peritoneum, 
and  in  about  50  per  cent,  of  newborn  infants  the  processus  vaginalis 
is  still  open. 

Congenital  Hydrocele. — In  this  variety  the  fluid  occupies  a  position 
in  the  umbilical  canal  between  the  peritoneal  cavity  and  the  tunica 
vaginalis.  The  fluid  will  flow  back  into  the  abdominal  cavity  if  the 
child  is  placed  in  the  horizontal  position  and  a  moderate  amount  of 
taxis  emplo^^ed. 

Hydrocele  of  the  Tunica  Vaginalis. — This  is  the  most  common  form 
and  is  irreducible.  The  inguinal  canal  becomes  closed  off  from  the 
abdominal  cavity,  but  still  communicates  with  the  tunica  vaginalis. 
The  tumor  is  oval,  firm  to  the  touch,  translucent,  and  usually  one- 
sided. Fluctuation  can  generally  be  obtained.  Ordinarily  the  testicle 
cannot  be  found  by  manipulation. 

Encysted  Hydrocele  of  the  Cord. — This  consists  of  a  small  amount 
of  fluid,  usually  about  one  or  two  drams,  surrounding  a  portion  of  the 
cord.  There  is  no  communication  with  the  tunica  vaginalis  testis, 
and  the  tumor  is  irreducible.  The  same  condition  when  found  in 
girls  is  called  encysted  hydrocele  of  the  canal  of  Nuck,  and  requires 
the  same  treatment. 

Diagnosis. — About  the  only  condition  with  which  hydrocele  is  apt 
to  be  confounded  is  an  irreducible  hernia.  A  hard,  tense,  irreducible 
tumor,  which  has  been  present  for  some  time,  which  has  not  been 


OBLITERATION  OF   THE   BILE   DUCTS  99 

and  cannot  be  reduced,  which  produces  no  symptoms,  and  is  not 
painful  on  pressure,  is  a  hydrocele. 

Treatment. — The  simplest,  and  often  the  only  treatment,  is  to 
puncture  the  cyst  and  draw  off  the  fluid,  which  is  best  accomplished 
with  a  small  aspirating  needle.  If  after  three  such  withdrawals  cure 
has  not  resulted,  surgical  measures  should  be  resorted  to.  The  best 
treatment  for  the  reducible  form  of  hydrocele  is  to  return  the  fluid  by 
means  of  gentle  taxis  into  the  abdominal  cavity,  and  then  apply  a 
truss  with  the  hope  that  pressure  may  not  only  prevent  the  return  of 
the  fluid,  but  also  gradually  produce  obliteration  of  the  canal.  Injec- 
tions of  iodine  into  the  hydrocele  sac  are  not  to  be  recommended; 
the  subsequent  inflammation  is  often  very  severe,  and  in  those  patients 
in  whom  the  canal  is  still  open,  the  procedure  is  attended  by  a  certain 
amount  of  danger.  Phimosis  which  causes  tenesmus  and  consequent 
increase  of  intra-abdominal  pressure  should  be  operated  upon.  The 
surgical  operation,  of  choice,  is  extirpation  of  the  hydrocele  sac. 


Fig.  16. — Hydrocele  in  an  infant  aged  six  months. 

OBLITERATION  OF  THE  BILE  DUCTS. 

The  common  hepatic  or  cystic  duct  may  be  obliterated  as  the  result 
of  imperfect  development.  A  narrowing  of  the  lumen  of  one  or  more 
of  these  ducts  results  in  inflammation  of  their  lining  membrane  which 
finally  stops  entirely  the  flow  of  bile.  Either  the  common  duct  alone 
may  be  affected,  or  the  hepatic  or  cystic  duct  may  be  the  one  involved. 
Intra-uterine  peritonitis  is  probably  secondary  to  the  atresia  of  the 
bile  ducts.  In  about  10  per  cent,  of  these  cases  there  is  a  history  of 
syphilis.  The  gall-bladder  is  small,  often  onl}^  rudimentary,  although 
in  atresia  of  the  common  duct  it  may  be  greatly  distended.  The 
liver  is  usually  much  enlarged  and  shows  the  changes  due  to  chronic 
interstitial  hepatitis.  The  spleen  is  enlarged,  and  the  bile  duct  may  be 
reduced  to  a  fibrous  cord. 


100  CONGENITAL  MALFORMATIONS 

Symptoms. — ^All  the  tissues  and  organs  of  the  body  are  deeply 
jaundiced,  and  hemorrhages  beneath  the  skin,  with  vomiting  of  blood 
and  blood  in  the  stools,  occur  in  some  cases.  Jaundice  is  the  most 
marked  symptom;  it  develops  usually  within  a  few  days  after  birth, 
and  progressively  becomes  more  pronounced.  The  urine  is  very 
high-colored  owing  to  the  presence  of  bile  pigment.  Shortly  after 
birth  small  stools  composed  of  meconium  may  be  passed;  later  the 
stools  are  clay-colored  or  white,  and  examination  shows  them  to 
contain  no  bile  except  in  those  cases  where  the  blocking  is  limited 
to  the  cystic  duct.  The  child  may  be  well-nourished  at  birth,  but  soon 
loses  flesh,  and  death  from  inanition  occurs  in  the  course  of  a  few  weeks 
to  four  months.  Marked  abdominal  distention  with  toxemia,  as 
evidenced  by  convulsions,  is  a  not  unusual  symptom,  and  convulsions 
are  a  not  uncommon  cause  of  death  in  those  infants  who  live  but  a 
few  weeks. 

Treatment. — This  exerts  no  influence  upon  the  symptoms  or  the 
course  of  the  disease. 

SPINA  BIFIDA. 

Spina  bifida  consists  of  a  fissure  in  the  spinal  canal  with  a  hernia 
of  some  portion  of  its  contents,  the  portion  that  protrudes  forming 
a  tumor  posteriorly.  Fluid  is  always  present  in  the  tumor.  It  is  one 
of  the  most  common  congenital  malformations.  The  walls  of  the 
tumor,  according  to  the  intra-uterine  period  in  which  the  defective 
development  occurs,  may  contain  a  portion  of  one  or  of  all  the  follow- 
ing structures:  Spinal  cord,  nerves,  meninges,  and  vertebral  arches. 
The  tumor,  in  rare  instances,  instead  of  appearing  posteriorly  through 
a  fissure  in  the  bony  spine,  mav  project  anteriorly  into  the  thorax 
or  abdomen.  These  tumors  resemble  hernia  of  the  brain  in  pathology 
and  in  mode  of  development.  There  are  several  varieties  of  spina 
bifida,  although  all  present  two  features  in  common:  a  defect  in  the 
bony  spinal  column  and  a  lesion  in  the  spinal  canal.  All  result  from  an 
error  in  development.  The  spinal  canal  closes  at  different  places  at 
varying  stages  in  the  development  of  the  fetus,  the  lower  lumbar  and 
upper  cervical  being  the  last  portions  to  unite,  and  these  two  locations 
are  the  places  in  which  the  deformity  usually  occuts.  In  all  forms 
;r-ray  plates  will  show  the  bony  defect. 

Spinal  Meningocele. — In  this  variety  of  spina  bifida  a  tumor  is 
found  in  the  cervical  or  sacral  region.  It  is  translucent,  globular, 
and  pedunculated.  As  a  rule,  there  is  no  disturbance  of  sensation  or 
motion.  The  tumor  contains  only  the  spinal  meninges  and  cerebro- 
spinal fluid.  The  fluid  is  in  the  subarachnoid  space.  The  opening  into 
the  spinal  canal  is  small,  and  the  skin  over  the  tumor  is  firm  and 
healthy.  This  form  may  become  quite  large,  but  spontaneous  rupture 
is  not  very  likely  to  occur  owing  to  the  healthy  condition  of  the 
overlying  skin.  Patients  with  this  form  of  tumor  may  live  for  years — 
in  fact,  well  into  adult  life.  It  is  the  least  dangerous  form  to  operate 
upon,  and  the  easiest  to  cure  by  an  operation. 


SPINA   BIFIDA  101 

Myelomeningocele. — This  is  the  most  coininon  form  of  spina  hihda, 
especially  in  the  hnnbosacral  region.  The  fluid  is  in  the  anterior 
arachnoid  cavity.  The  tumor  is  not  large,  but  has  a  large  base,  is  soft, 
flat,  elastic,  and  not  pedunculated.  Often  it  is  covered  only  in  part 
by  skin;  the  central  portion  of  the  tumor  being  covered  by  a  thin 
tissue,  commonly  showing  ulceration.  A  depression  in  this  central 
part  marks  the  position  of  the  attachment  of  the  cord.  The  tumor  is 
composed  of  the  prolapsed  spinal  cord.  Paralysis  of  the  bladder, 
rectum  and  lower  limbs,  and  deformities  of  the  foot  may  accompany 
this  form. 

Myelocystocele. — This  is  the  rarest  form.  It  is  found  in  the  dorsal, 
lumbar,  or  sacral  regions,  and  may  be  combined  with  abdominal 
fissures  and  club-foot.  The  tumor  is  round  with  a  wide  base,  is  elastic, 
transparent,  and  fluctuates.  It  may  also  be  associated  with  hydro- 
cephalus, and  in  this  form  there  is  a  dilatation  of  the  central  canal 
of  the  cord.  The  wall  around  the  sac  is  composed  of  medullary  sub- 
stance. If  hydrocephalus  is  present  the  prognosis  is  less  favorable, 
and  pressure  upon  the  anterior  fontanelle  causes  an  increase  in  the 
size  of  the  tumor.  There  is  usually  no  paralysis.  The  skin  covering  the 
tumor  is  very  thin. 

Spina  Bifida  Occulta. — This  consists  of  a  slight  fissure  or  defect 
at  the  inferior  end  of  the  spinal  canal;  it  is  covered  by  normal  skin. 
Here,  as  in  the  other  forms,  the  .r-rays  will  reveal  the  bony  defect.  A 
small  tumor  may  show  itself  or  none  may  exist,  the  spinal  defect  being 
indicated  only  by  a  slight  depression  or  dimple  in  the  overlying  skin. 
A  swelling  in  the  sacral  region  associated  with  any  neighboring  trophic 
changes,  or  paralysis  of  the  rectum,  bladder,  or  lower  extremities 
suggests  a  probable  spina  bifida  occulta.  This  form  is  not  incompatible 
with  a  long  life  (Fig.  17). 

Symptoms. — A  tumor  is  always  present  at  birth,  and  is  usually 
tense  and  fluctuating.  It  is  either  directly  in  the  median  line  or  slightly 
to  the  side  of  this  line.  The  skin  covering  the  tumor  may  be  well 
nourished  or  atrophic.  The  usual  location  is  in  the  lumbosacral 
region;  it  may  attain  a  very  large  size  if  the  skin  covering  is  healthy. 
If,  however,  the  skin  covering  is  thin,  rupture  and  early  death  generally 
result. 

All  the  varieties  of  spina  bifida  contain  fluid  which  may  be,  at  least 
partially,  returned  to  the  spinal  canal  by  gentle,  continuous  pressure; 
if  the  sac  is  relaxed  and  soft,  any  contents  may  be  clearly-  and  firmly 
compressed  and  possibly  outlined.  The  tension  within  the  sac  is  often 
increased  by  holding  the  child  in  the  upright  position,  especially  if 
it  kicks  and  screams.  If  the  tumor  is  translucent  it  may  be  largeh' 
reduced,  and  if  no  central  mass  is  palpable  it  points  to  the  absence  of 
any  prolapsed  portion  of  the  spinal  cord.  Untreated  cases  sooner  or 
later  develop  infection  of  the  skin  covering  the  sac,  with  subsequent 
spinal  meningitis  and  death.  Ulceration  of  the  skin  may  take  place, 
with  rupture  of  the  sac,  the  rupture  healing,  but  again  breaking  open, 
and  finally  death  from  infection  results.  Paralysis,  as  it  depends 
upon  the  amount  of  injury  done  to  the  cord  or  the  existence  of  the 


102 


CONGENITAL  MALFORMATIONS 


cord  ill  the  tumor,  is  rarely  present  in  spinal  meningocele.  In  a  cervical 
tumor  paralysis  is  rare,  being  much  more  common  in  the  lumt^osacral 
forms.  Paralysis,  to  a  certain  extent,  depends  upon  the  location  of 
the  tumor;  if  low  down  in  the  sacral  region  and  only  the  cauda  equina 
is  involved,  the  bladder  and  rectum  may  escape,  and  the  legs  be  only 
partially  paralyzed.  A  very  small  spinal  opening  may  occasionally 
be  closed  by  inflammatory  exudate,  resulting  in  a  spontaneous  cure; 
this,  however,  occurs  so  rarely  that  it  is  not  to  be  expected. 


Fig.  17. — Spina  bifida  occulta. 


Trophic  changes,  as  shown  by  ulceration,  are  not  uncommon. 
Motion  and  sensation  may  be  normal  or  disturbed  in  the  legs,  and 
incontinence  of  urine  or  feces  may  be  present.  Other  deformities  of 
the  body  are  not  uncommon.  A  depression  marks  the  centre  of  the 
myelocystocele,  and  the  fissure  in  the  entire  vertebral  column  is 
usually  palpable. 

Diagnosis. — The  different  forms  of  spina  bifida  are  difficult  to 
diagnose  but  the  location  of  the  tumor  is  of  some  assistance.    A  menin- 


ATRESIA  OF  THE   VAGINA,  LABIA,   AND   URETHRA        103 

gocele  is  apt  to  be  traiislucciit  hikI  pedunculated,  and  sliows  no  e\idence 
of  spinal  fissure;  it  is  irnportant  to  differentiate  this  form  f)n  account 
of  the  better  results  following  operation.  ^Myelomeningocele  is  apt 
to  be  associated  with  paralysis,  a  depression  exists  in  the  centre  of  the 
tumor,  it  has  a  broad  base,  and  on  palpation  the  bony  fissure  can  usually 
be  distinctly  felt.  The  tumor  is  rarely  large,  and  is  not  apt  to  be 
pedunculated.  Myelocystocele  is  the  form  most  apt  to  be  asso- 
ciated with  hydrocephalus,  and  pressure  upon  the  anterior  fontanelle 
increases  the  size  of  the  tumor. 

Prognosis. — The  prognosis  varies  according  to  the  character  of  the 
contents  of  the  tumor,  and  the  integrity  of  its  skin  covering.  In 
spinal  meningocele  operation  offers  a  reasonable  hope  of  cure,  provided 
hydrocephalus  does  not  exist.  In  other  forms,  if  there  is  associated 
paralysis  or  hydrocephalus,  the  prognosis  is  grave,  although  the 
existence  of  paralysis  does  not  necessarily  contra-indicate  operation. 
Hydrocephalus  may  develop  after  a  successful  operation. 

Treatment. — All  tumors  should  be  protected  from  pressure.  The 
skin  covering  them  should  be  kept  clean,  and  the  tumor  supported 
by  an  air  cushion  or  rubber  ring.  A  healthy  well-developed  child 
should  be  operated  upon,  but  a  wasted,  atrophic  infant  is  less  able  to 
bear  operation.  If  the  tumor  is  well  covered  by  healthy  skin,  and  not 
increasing  rapidly  in  size,  it  is  a  good  plan  to  wait  until  the  child  is 
six  months  old,  and  is  better  able  to  withstand  the  shock  of  operation; 
at  the  same  time,  in  my  experience  I  have  found  it  much  better  to 
operate  at  once  if  the  infant  and  tumor  are  not  receiving  the  best  care 
hygienically  and  dietetically.  The  usual  operative  procedure  consists 
of  the  excision  of  the  sac,  and  a  plastic  operation  to  cover  up  the  defect. 
Recovery  as  to  life  is  very  common,  but  paralysis  or  trophic  symptoms 
may  persist. 

In  estimating  the  possible  benefits  from  operative  treatment,  the 
results  commonly  depend  upon  the  strength  of  the  patient  and  the 
condition  of  the  sac.  The  removal  of  the  entire  growth  by  ligation 
or  by  injections  is  not  warranted.  Paralysis  does  not  necessarily 
contraindicate  operation,  as,  in  a  few  reported  cases,  a  cure  of  the 
spina  bifida  has  followed  surgical  interference,  and  the  paralysis  has 
partially  improved. 

ATRESIA  OF  THE  VAGINA,  LABIA,  AND  URETHRA. 

Atresia  of  the  vagina  is  usually  the  result  of  an  imperforate  hymen 
or  a  septum.  It  may  not  be  discovered  until  the  time  for  menstruation 
arrives.  Perforation  or,  if  necessary,  removal  of  a  portion  of  the 
septum,  and  packing  the  opening  with  gauze  is  usually  all  that  is 
necessary  to  effect  a  cure.  If  the  condition  is  discovered  in  infancy, 
the  obstruction  can  ordinarily  be  easily  overcome  by  the  passage  of  a 
probe  and  packing  the  opening  with  gauze.  At  this  period  the  tissues 
are  only  slightly  vascular  and  the  membrane  extremely  delicate; 
later  in  life  the  septum  becomes  tougher  and  much  more  vascular. 
The  labia  minora  may  be  more  or  less  firmly  adherent.    Their  separa- 


104  CONGENITAL  MALFORMATIONS 

tioii  is,  however,  as  a  rule  easily  accomplished,  and  if  a  small  piece  of 
gauze  is  inserted  between  them  to  prevent  subsequent  adhesions  a 
cure  is  quickly  effected.  Atresia  of  the  urethra  will,  if  complete, 
produce  anuria.  A  small,  blunt  probe  will  often  penetrate  the  thin 
membrane  which,  in  the  majority  of  cases,  is  the  cause  of  the  obstruc- 
tion, and  quickly  and  permanently  relieve  the  condition.  A  contracted 
meatus  may  cause  difficult  and  slow  micturition  with  tenesmus.  The 
meatus  may  be  dilated,  or  it  may  be  enlarged  by  a  slight  incision. 

HYPOSPADIAS  AND  EPISPADIAS. 

Hypospadias. — Hypospadias  is  caused  by  arrested  development  in 
the  corpus  spongiosum.  In  this  developmental  process  the  urethral 
groove  becomes  a  canal,  and  if  the  fusion  of  the  portions  necessary  to 
form  it  be  imperfect,  an  opening  is  left  at  some  point  in  its  lumen. 
The  most  common  seat  for  this  deformity  is  at  the  base  of  the  glans, 
the  defect  appearing  in  the  lower  portion  of  the  urethra  and  the 
adjacent  part  of  the  corpus  spongiosum.  The  arrest  of  development 
occurs  at  or  before  the  fourth  month  of  intra-uterine  life.  If  the 
urethra  opens  at  the  base  of  the  glans,  it  is  called  glandular  hypo- 
spadias; if  between  the  scrotum  and  the  glans,  it  is  called  penile  hypo- 
spadias; and  if  behind  the  scrotum  perineal  hypospadias.  In  the 
latter  the  scrotum,  and  even  the  perineum,  may  be  fissured,  and  if  the 
testes  are  in  the  abdominal  cavity  the  sex  of  the  infant  may  be  tem- 
porarily in  doubt.  In  man}'  cases  there  is  more  or  less  difficulty  in 
micturition;  in  others  control  of  the  bladder  seems  to  be  normal.  The 
treatrrfent  is  purely  surgical.  The  operation  is  a  delicate  one,  but  in 
the  hands  of  a  skilful  specialist  the  result  is  often  quite  satisfactory,  and 
the  patient's  condition  is  usually  much  improved.  The  most  suitable 
time  for  the  operation  is  when  the  child  is  four  or  five  years  old. 

Epispadias. — Epispadias  is  due  to  an  arrst  of  development  occurring 
in  the  same  manner  as  in  hypospadias.  In  this  condition  the  urethra 
opens  on  the  dorsum  of  the  penis;  there  is  a  defect  in  the  upper  wall 
of  the  urethra,  and  the  adjacent  portion  of  the  corpus  cavernosum. 
Epispadias  is  a  very  rare  condition;  hypospadias  is  quite  common. 
Exstrophy  of  the  bladder  may  be  associated  with  epispadias;  persons 
with  this  condition  are  apt  to  be  depressed  mentally,  and  to  suffer 
from  incontinence  of  urine,  the  dribbling  of  which  produces  excoriation 
of  the  skin  and  causes  a  most  disagreeable  ammoniacal  odor;  infection 
of  the  urethra  and  cystitis  are  not  uncommon  complications.  The 
treatment  is,  of  course,  purely  surgical,  although  local  applications  will, 
to  a  certain  extent,  relieve  the  irritation  caused  by  the  dribbling  of 
urine.  The  operation  should  be  attempted  only  by  a  specialist,  as  it 
is  a  very  delicate  and  difficult  one;  but,  in  view  of  the  almost  constant 
nervous  and  depressed  condition  caused  by  the  continuous  dribbling 
of  urine,  it  is  only  proper  to  give  the  child  an  opportunity  to  be 
benefited  by  surgical  treatment.  The  results  of  operation  are  fairly 
satisfactory,  and  the  best  time  for  it  to  be  performed  is  when  the 
child  is  six  or  seven  years  old. 


CHAPTER  VII. 
DISEASES  OF  THE  NEWBORN. 

GENERAL  PARALYSIS  OF  THE  NEWBORN. 

Prenatal  Paralysis. — Etiology. — Prenatal  paralysis  includes  all  those 
cases  in  which  the  paralysis,  or  the  cause  of  the  paralysis,  develops 
before  the  onset  of  labor.  Consequently  it  comprises  all  cases  of 
defective  cerebral  development,  such  as  porencephalus,  microcephalus, 
brain  atrophy,  congenital  cysts,  and  all  brain  lesions  of  such  a  nature 
as  to  cause  paralysis  at  birth,  or  some  mental  or  physical  defect  that 
shows  itself,  perhaps,  months  or  years  after  birth;  also  agenesis 
corticalis,  in  which  one  finds  defective  development  of  the  cellular 
elements  of  the  brain  cortex  more  or  less  widely  distributed,  but 
especially  marked  in  the  pyramidal  cells.  The  origin  of  the  paralysis 
is  always  intra-uterine,  the  lesion  is  prenatal  and  occurs  before  labor 
begins. 

If  the  mother  while  pregnant  suffers  from  any  severe  systemic 
disease,  has  uremic  convulsions,  or  sustains  a  severe  blow  or  fall 
on  the  abdomen,  this  form  of  paralysis  may  be  induced.  Arrested 
development  of  the  brain  is  undoubtedly  responsible  for  some  of  the 
cases,  and  syphilis,  insanity,  alcoholism,  and  pyogenic  infections  in  the 
parents  are  supposed  to  be  more  or  less  effective  in  a  small  percentage 
of  the  patients,  while  secondary  degeneration  in  the  lateral  columns 
of  the  cord  is  noted  in  a  considerable  number. 

Symptoms. — The  sj^mptoms  are,  of  course,  in  proportion  to  the  extent 
of  the  lesion.  They  may  at  birth  be  very  mild,  and  only  the  slightest 
impairment  of  the  mental  power  and  gait  be  present ;  usually,  however, 
the  paralysis  is  marked  at  birth,  is  spastic  in  type,  and  associated  with 
great  mental  deterioration,  the  patient  being  commonly  a  helpless  and 
hopeless  invahd. 

Diplegia  and  paraplegia  are  usually  present,  although  hemiplegia 
also  may  occur.  The  child  may  be  microcephalic,  or  show  evidences 
of  cranial  or  facial  asymmetry  with  arched  palate  and  the  stigmata  of 
degeneration. 

Prognosis. — This  depends  upon  the  extent  of  the  brain  lesion  or  the 
extent  of  the  lack  of  brain  development.  Most  cases  are  very  little 
benefited  by  treatment.  In  the  mildest  cases  something  may  often  be 
accomplished  by  judicious  feeding,  good  hygiene,  massage,  and 
electricity. 

Treatment. — The  infant  should  receive  all  possible  care  dietetically 
and  hygienically.  Its  general  nutrition  should  be  kept  at  as  high  a 
level  as  possible,  and  every  effort  should  be  made  under  instructions 
from  the  mother  or  trained  assistant  to  develop  whatever  brain  capacity 


106  DISEASES  OF   THE  NEWBORN 

tlie  child  may  possess^  j\Iany  })atieiit.s  are  best  eared  for  in  iustitiitious, 
where  the  results  of  treatment  are  often  remarkably  good.  Slight 
gastro-intestinal  distm-bances  may  cause  a  marked  temporary  increase 
in  the  nervous  symptoms,  and  it  is,  therefore,  important  to  map 
out  for  these  children  such  a  diet  as  they  can  easily  digest.  To  control 
convulsions,  and  possibly  with  the  hope  of  preventing  them,  the 
bromides  and  iodides  can  be  used.  Iodides  internally  and  mercury  by 
inunction  have  been  recommended. 

Natal  Paralysis. — Etiology. — Natal  paralysis  includes  all  those  cases 
of  paralysis  in  the  newborn  in  which  the  lesion  takes  place  either  during 
labor  or  immediately  after  birth.  Hemorrhage,  meningeal  in  origin, 
is  the  cause  in  a  great  majority  of  the  cases,  and  is  usually  induced  by 
a  tedious  labor,  a  difficult  forceps  delivery,  or  a  breech-presentation. 
The  fact  that  birth  palsies  are  most  common  in  firstborn  children 
suggests  that  labor  is  the  cause.  Meningoencephalitis,  followed  by 
degenerative  changes  in  the  cortical  motor  area  or  other  portions  of  the 
brain,  is  among  the  conditions  fourid.  The  meningeal  hemorrhage  that 
produces  the  paralysis  may  be  a  part  of  the  bleeding  in  hemorrhagic 
disease  of  the  newborn.  The  hemorrhage  may  occur  in  the  brain 
substance,  it  may  be  at  the  base  of  the  brain  in  the  cerebellar  region, 
or  in  the  region  of  the  occipital  lobes  of  the  cerebrum,  or  at  the  con- 
vexity. It  may  be  profuse  or  slight,  diffused  or  locaHzed,  and  the 
blood  may  come  from  the  pia,  the  cerebral  veins,  or  a  sinus.  In  still- 
born children,  hemorrhage  is  often  found  in  the  upper  membranes  of 
the  cord.  A  few  cases  have  been  reported  as  the  result  of  premature 
birth,  and  asph\Tda  is  a  recognized  cause.  Secondary  sclerosis  and 
atrophy  may  develop  and  involve  large  areas  of  the  brain,  followed 
by  secondary  degenerative  changes  in  the  cord,  especially  the  lateral 
columns. 

Symptoms. — Asphyxia  and  paralysis  are,  as  a  rule,  present  at  birth, 
or  appear  within  the  first  twelve  hours  after  birth.  Convulsive  twitch- 
ings  and  paralysis  may  not,  however,  develop  until  several  days 
after  delivery.  Bulging  of  the  fontanelle  and  slow  pulse  are  suggestive 
of  cerebral  hemorrhage,  and  nose  bleed  or  blood  in  the  pharynx  are 
common  symptoms.  A  slight  lesion  is  often  unnoticed  at  birth,  and 
remains  unobserved  until  the  child  is  some  months  old,  when  its  failure 
to  take  notice,  to  creep,  to  walk,  to  talk,  and  otherwise  to  develop 
normally  forces  itself  upon  the  attention  of  the  parents,  and  a  physician 
is  consulted.  It  may  not  walk  until  almost  two  years  of  age,  and 
then  the  gait  is  very  unsteady.  ^Mental  development  is  slow,  and  in 
early  infancy  acute  attacks  of  weakness  associated  with  cyanosis  may 
occur.  If  not  seen  early  by  the  physician,  such  cases  are  apt  to  be 
ascribed  to  convulsions  occurring,  perhaps,  months  after  birth,  the 
convulsions  being  really  due  to  the  injury  at  birth,  and  merely  a 
symptom  of  the  progressive  changes  following  the  birth  lesion. 

Athetoid  movements,  if  present,  will  suggest  the  brain  origin  of 
these  cases,  and  epilepsy  as  a  later  condition  is  very  common.  The 
convulsions  often  begin  in  the  paralyzed  limb  and  spread  over  the 


GENERAL  PARALYSIS  OF   THE  NEWBORN  107 

eiitiiv  Ixxly,  and  may  be  associated  witli  opistJiotoiios.  If  the  lesion 
is  extensive  convulsions  are  common,  and  parajilegia  and  diplegia 
develop  early,  with  coma  and  possibly  early  death. 

The  symptoms  may  be  merely  those  of  a  slight  monoplegia  or  none 
at  all  may  be  noticed  by  the  parents;  later  a  physician  is  consulted 
because  the  child  is  backward.  An  examination  of  the  child  may  now 
reveal  strabismus,  poor  gait  with  slight  spasticity  and  exaggerated 
knee-jerks,  and  backwardness  in  walking  and  talking.  The  history 
of  the  birth  is  often  one  of  prolonged  and  difficult  labor. 

Where  convulsions  occur,  they  may  be  limited  to  the  arm  or  face, 
or,  after  beginning  in  one  portion,  may  involve  the  rest  of  the  body. 
Slow  and  irregular  respiration  is  suggestive  of  an  intracranial  hemor- 
rhage, as  are  also  a  slow,  weak  pulse  and  increased  reflexes. 

These  patients  may  show  nystagmus  and  change  in  the  pupils. 
Convulsions  are  especially  apt  to  be  associated  with  a  cortical  lesion. 
After  the  spastic  condition  of  the  arm  or  leg  has  lasted  for  a  few  days, 
hemiplegia  or  diplegia  may  appear.  If  the  convulsions  develop  within 
the  first  few  days  of  life,  they  quite  commonly  cease  when  the  child  is 
two  weeks  old,  only,  however,  to  reappear  after  an  interval  of  one, 
two,  or  three  months.  During  this  intervening  period  the  myelin 
sheaths  of  the  pyramidal  tracts  are  developed,  and  in  consequence  a 
communication  between  the  brain  and  cord  is  establshed  which  results 
in  a  spastic  hemiplegia  and  a  return  of  the  convulsions. 

The  fact  should  be  noted  that  no  matter  w^hat  the  character  of  the 
symptoms  at  the  onset,  spastic  paralysis  commonly  develops,  the 
paralysis  being  usually  most  marked  and  persistent  in  the  arm.  The 
extent  of  the  paralysis  may  vary  from  complete  loss  of  power  to  a 
loss  so  slight  that  it  is  manifested,  perhaps,  only  after  prolonged 
exertion.  If  at  birth  the  child  is  drowsy  or  dull  with  irregular  respira- 
tion, the  hemorrhage  is  probably  profuse,  and  the  child  is  apt  to  die 
within  the  first  twelve  to  thirty-six  hours.  If  the  child  is  born  dead, 
the  hemorrhage  is  usually  extensive  and  is  apt  to  be  at  the  base  of  the 
brain.  If  the  child  is  asphyxiated  at  birth,  the  prognosis  is  better  if  it 
can  be  made  to  breathe  without  much  difficulty,  and  is  able  to  nurse 
within  the  first  few  hours. 

Diagnosis. — Mild  cases  affecting  one  limb  may  suggest  Erb's  palsy 
or  an  anterior  poliomyelitis ;  the  latter  usually  aftects  groups  of  muscles 
in  a  limb,  but  not  an  entire  limb.  Reflexes  are  absent;  the  limb  is 
flaccid  with  marked  wasting,  the  reaction  of  degeneration  is  present, 
but  there  is  no  mental  impairment.  Poliomyelitis  comes  on  a  con- 
siderable time  after  birth,  and  is  usually  preceded  for  from  twenty-four 
to  forty-eight  hours  by  a  more  or  less  definite  group  of  symptoms. 

In  natal  paralysis  convulsions  are  common,  mental  impairment  is 
often  noted,  the  reflexes  are  increased,  and  a  spastic  paralysis  may  be 
present.  The  paralysis  is  apt  to  be  paraplegia,  diplegia,  or  hemiplegia, 
but  rarely  monoplegia.    Athetoid  movements  may  be  noticed. 

Prognosis. — ^The  prognosis  depends  upon  the  location  and  extent 
of  the  injury,  and  the  degenerative  changes  that  follow.    It  may  vary 


108  DISEASES  OF   THE  XEWBORX 

from  the  slightest  loss  of  mental  jjowei-  with  trivial  paralysis  to  idiocy 
with  extensi^■e  paralysis. 

Treatment. — The  skilful  handling  of  difficult  labor  cases  is  impor- 
tant, and  when  to  apply  and  Avhen  not  to  apply  the  forceps  is  often 
a  difficult  question  to  decide.  As  soon  as  the  child  is  born,  its  head 
should  be  raised  and  kept  elevated  and  a  small  ice-cap  applied  with  the 
hope  of  at  least  preventing  further  hemorrhage.  The  bowels  should  be 
thoroughly  moved,  and  the  child  kept  absolutely  quiet. 

If  convulsions  are  frequent  and  severe,  bromide  of  soda,  5  grains, 
with  chloral  hydrate,  ^  grain,  should  be  given  exery  two  or  three 
hours  by  the  mouth  or  rectum,  and  continued  as  long  as  the  symptoms 
persist;  or  chloroform  may  be  gi^'en  cautiously  by  inhalation.  If 
possible  the  general  health  of  the  child  should  be  kept  up,  and  especial 
attention  be  paid  to  the  nutrition  of  the  paralyzed  part,  every  possible 
endeavor  being  made  to  prevent  contractures.  The  best  of  food, 
abundance  of  fresh  air,  massage,  and  passive  exercises  are  all  of 
advantage. 

Braces  may  be  of  assistance,  and  lengthening,  cutting,  and  trans- 
planting of  tendons  may  be  necessary.  Short  school  hours  should  be 
the  rule  for  these  children;  if  nervous  and  highstrung,  school  attend- 
ance should  be,  at  least  temporarily,  given  up. 

If  the  position  of  the  clot  can  be  accurately  determined  by  localized 
convulsions  or  paralysis,  a  surgical  operation  should  be  performed  for 
its  removal,  especially  in  those  cases  where,  in  spite  of  medical  treat- 
ment, alarming  symptoms  continue.  The  difficulty,  of  com-se,  is  to 
locate  the  clot  accurately.  ^Medical  literature  now  records  a  number 
of  instances  where  the  operation  has  been  successfully  accomplished. 
If  a  meningeal  hemorrhage  is  diagnosed,  and  the  anterior  fontanelle 
is  bulging,  puncture  of  the  fontanelle  may  be  performed  at  once  with 
the  hope  of  drawing  of!  some  of  the  blood  before  it  clots.  A  needle 
is  introduced  to  a  depth  of  one-sixth  to  one-fourth  of  an  inch,  as  far 
from  the  longitudinal  sinus  as  possible,  and  an  attempt  made  to  with- 
draw some  of  the  effused  blood.  If  any  blood  is  secured,  the  procedure 
is  of  value,  both  in  a  curative  sense  and  as  a  means  of  diagnosis. 

BIRTH  PALSIES. 

Erb's  Palsy  {Obstetric  Paralysis). — This  form  of  palsy  was  first 
described  by  Duchenne,  and  later  more  carefully  studied  by  Erb. 
The  condition  is  due  to  an  injury  of  the  brachial  plexus  at  birth.  It 
may  be  caused  by  pressure  from  the  application  of  the  forceps,  or 
during  labor  by  a  contracted  pelvis.  It  is  especially  common  in 
breech  presentations,  rarely  occurring  in  a  spontaneous  delivery.  It 
may  be  the  result  of  traction  in  the  axilla  during  delivery,  or  upon  the 
shoulder,  traction  necessarily  being  employed  in  order  to  deliver  the 
after-coming  head;  the  injury  may  also  be  produced  in  bringing 
down  the  arms  which  are  extended  above  the  head.  The  lesions  consist 
of  a  stretching  and  tearing  of  the  nerves,  and,  to  a  certain  extent,  of  the 


BIRTH   PALSIES 


109 


surrounding  tissues,  which  result  in  a  localized  area  of  inflammation, 
and  possibly  subsequent  degeneration. 

Symptoms. — The  symptoms  may  be  severe,  or  they  may  be  very 
slight.  The  loss  of  power  in  the  arm  may  be  noticed  immediately  at 
birth,  or,  in  mild  cases,  not  for  some  weeks.  The  arm  may  hang  limp 
and  helpless  without  any  power  of  motion  at  the  shoulder.  In  old 
cases  it  is  often  noticed  that  the  shoulder  tends  to  drag  lower  than 
that, on  the  healthy  side.  The  nerves  usually  injured  are  the  fifth 
and  sixth  cervical.  According  to  Erb,  a  lesion  at  the  spot  where  the 
sixth  cervical  passes  between  the  scalenus  muscles  will  produce  the 
classical  symptoms  of  Erb's  palsy.  The  paralysis  affects,  wholly  or  in 
part,  the  deltoid,  biceps,  supinator  longus 
and  brevis,  supra-  and  infraspinatus, 
and  the  brachialis  anticus.  The  upper 
arm  is  rotated  inw^ard;  the  forearm  is 
pronated,  and  the  palm  is  turned  more 
or  less  outward.  Supination  at  the  elbow 
is  absent  and  motion  at  the  wrist-joint  is 
normal  with  the  possible  exception  of  more 
or  less  loss  of  extension.  Flexion  is  always 
normal  at  the  wrist.  The  forearm  is 
not  affected.  The  hands  may  be  normal 
or  show  a  slight  loss  in  power  of  flexion. 

There  may  be  disturbance  of  sensa- 
tion on  the  outer  surface  of  the  arm 
in  those  portions  supplied  by  the  mus- 
culocutaneous nerves  and  the  axillary 
nerve.  The  sensibility  of  the  inner  sur- 
face of  the  arm  remains  normal.  If  the 
child  does  not  tend  to  recover,  trophic 
changes  develop,  contraction  of  the  af- 
fected muscles  takes  place,  and  the 
shoulder  blades  become  prominent.  The 
bones  of  the  arm  fail  to  grow  normally, 
and  subluxation  of  the  shoulder  which 
tends  still  further  to  interfere  with  motion 

may  develop.  A  fracture  of  the  clavicle  or  humerus,  or  a  separation 
of  the  epiphysis  of  the  upper  end  of  the  humerus,  is  a  complication 
which  is  occasionally  found  at  birth  and  renders  the  diagnosis  and 
prognosis  of  Erb's  palsy  more  difficult. 

Diagnosis. — An  old  case  of  Erb's  palsy,  seen  for  the  first  time,  may 
simulate  anterior  poliomyelitis.  Erb's  palsy  develops  at  birth  or  soon 
after,  and  infantile  paralysis  always  at  a  considerable  period  after 
birth.  Subluxation  of  the  shoulder  is  suggestive  of  Erb's  palsy, 
and  the  group  of  muscles  affected  in  Erb's  palsy  is  not  often  found 
affected  in  infantile  paralysis.  Paralysis  due  to  syphilis  can  be  differ- 
entiated by  the  history  and  other  evidences  of  syphilis.  The  inward 
rotation  of  the  arm  resulting  from  a  separation  of  the  upper  epiphysis 
of  the  shoulder  can  he  diagnosed  by  the  x-rays. 


Fig.   IS.^Erb's  palsy. 


110 


DISEASES  OF   THE  NEWBORN 


Prognosis. — ^The  fewer  the  muscles  involved  and  the  earlier  the 
treatment  is  begun,  the  better  the  prognosis.  Most  cases  recover 
entirely,  although  a  few  in  spite  of  treatment  show  little  or  no 
improvement. 

Treatment. — If  the  muscles  respond  to  faradism  rapid  recovery 
often  results,  and  the  affected  muscles  should  be  treated  with  faradism 
every  day,  provided  they  respond;  if  they  do  not  respond,  galvanism 
should  be  employed.  Dail}^  massage  will  improve  the  nutrition  of  the 
parts,  and  tends  to  prevent  the  development  of  contractures.  For 
those  patients  who  have  been  treated  faithfully  and  systematically 
by  massage  and  electricity  for  some  months  without  benefit,  a  plastic 
operation  on  the  injured  nerves  and  tendons  is  worthy  of  consideration ; 
in  a  few  cases,  quite  satisfactory  results  have  followed  the  suturing 
of  the  involved  nerve  trunks. 


-FROM  FOURTH  CERVICAL 


TO  SCALENI  & 
LONGUS  COLLI 


THIRD 


POSTERIOR 
THORACIC 


£:0(;s~--\v. 


Fig.  19. — Plan  of  the  brachial  plexus.     (Gerrish.) 


Klmnpke's  Palsy. — In  contradistinction  to  Erb's  palsy,  or  the  upper 
arm  type,  is  the  form  described  by  Klumpke  and  called  the  lower 
arm  type.  The  muscles  involved  in  this  form  are  those  innervated 
by  the  seventh  and  eighth  cervical  and  the  first  dorsal  nerves.  These 
muscles  may  be  the  only  ones  involved,  or,  in  addition,  those  supplied 
by  the  fifth  and  sixth  cervical  nerves  may  also  be  affected. 

Symptoms. — ^A  single  muscle,  as  the  deltoid,  may  be  affected,  or 
all  the  muscles  of  the  arm  may  be  involved,  and  the  entire  arm 
and  hand  may  be  more  or  less  completely  paralyzed  with  loss  of 
sensation.     In  certain  cases,  in  addition  to  the  muscles  involved  in 


ALBUMINURIA  AND    URIC  ACID  INFARCTION  111 

Erb's  palsy,  the  subscapularis,  rhomboideus,  serratus  and  pectoralis 
major  may  be  affected.  The  lesion  is  occasionally  bilateral.  Eye 
symptoms  are  present,  due  to  the  involvement  of  the  sympathetic 
nerve  from  the  first  dorsal;  the  latter  connects  with  the  lower  portion 
of  the  brachial  plexus  (Fig.  19). 

The  opening  between  the  eyelids  is  narrow,  and  a  contraction  of  the 
pupil  is  present  which,  however,  reacts  well  to  light  and  accommo- 
dation. The  prognosis  and  treatment  are  the  same  as  in  Erb's  palsy, 
as  the  lesions  are  identical,  but  different  nerves  are  involved. 

Facial  Palsy. — The  paralysis  may  be  on  one  or  both  sides,  is  periph- 
eral in  origin,  and  may  involve  one  or  more  of  the  branches  of  the 
nerve.  It  is  usually  seen  in  children  delivered  by  forceps,  when  one  of 
the  blades  has  pressed  firmly  on  the  facial  nerve,  producing  an  injury 
to  the  nerve  sheath  and  the  nerve  fibers.  It  may  also  follow  delivery 
in  cases  of  contracted  pelvis.  The  prognosis  is  usually  favorable, 
all  traces  of  the  paralysis  disappearing,  as  a  rule,  in  the  first  few 
months  of  life. 

ALBUMINURIA  AND  URIC  ACID  INFARCTION. 

Albumin  in  the  form  of  nucleo-albumin  is  found  in  the  urine  of  the 
majority  of  infants  at  birth,  but  never  in  large  amounts.  As  a  rule 
it  persists  for  from  one  to  ten  days,  although  it  may  occasionally 
continue  for  a  month. 

During  the  first  few  days  of  life  infants  take  only  small  amounts  of 
liquids  in  the  form  of  breast  milk  and  water,  but  eliminate  con- 
siderable fluid  by  the  skin  and  breath  which  tends  to  lessen  the  amount 
of  urine  voided,  and  during  this  period  of  slight  urinary  secretion 
albuminuria  and  uric  acid  infarction  are  apt  to  appear.  That  these 
have  some  connection  with  the  quantity  of  fluids  ingested  is  shown  by 
the  fact  that  they  are  much  less  common  in  bottle-fed  babies  who 
invariably  receive  a  larger  amount  of  food  during  this  period  than 
those  fed  at  the  breast. 

The  urine  voided  immediately  or  soon  after  birth  is  normal,  and 
the  kidneys  of  stillborn  infants  rarely  show  uric  acid  infarction. 
These  infarcts  of  uric  acid  are,  however,  often  found  in  the  kidneys 
of  children  a  few  days  or  weeks  old,  and  consequently  must  develop 
after,  and  not  before  birth. 

The  same  rule  as  to  time  is  noticed  in  the  microscopical  findings. 
Normal  at  birth,  in  a  day  or  two  the  urine  becomes  cloudy  and  contains 
hyaline  and  epithelial  casts,  leukocytes,  and  epithelium  from  the 
kidney.  The  casts  are  found  much  more  commonly  in  breast-fed 
(40  per  cent.)  than  in  bottle-fed  (10  per  cent.)  infants.  The  brick- 
dust  stain  on  the  diapers  during  the  first  few  days  is  caused  by  urates. 
These  urinary  findings  are  all  apparently  due  to  uric  acid  infarcts  in 
the  kidneys,  and  are,  as  previously  mentioned,  largely  dependent 
upon  the  amount  of  water  and  milk  ingested  during  the  first  few  days 
or  weeks  of  life. 


112  DISEASES  OF   THE  NEWBORN 

It  is  a  question  whether  it  is  physiological  for  albuminuria  and  casts 
to  be  present  in  the  urine  of  the  newborn.  The  nucleo-albumin  must 
be  due  to  a  disturbance  of  the  kidney  function;  it  cannot  come  from 
the  blood  since  nucleo-albumin  does  not  exist  in  the  blood. 

BONE  INJURIES. 

As  a  result  of  injury  during  a  difficult  labor,  the  bones  of  the  infant 
may  be  more  or  less  seriously  injured.  This  is  more  commonly  seen 
in  the  bones  of  the  skull,  where  depressions  and  fractures  may  follow 
the  use  of  the  forceps,  although  the  same  conditions  may  be  found 
when  no  instruments  have  been  used.  The  parietal  bones  are  the  ones 
most  often  injured;  but,  unless  the  underlying  membranes  and  brain 
tissues  have  been  affected,  the  injury  may,  if  not  excessive,  be  produc- 
tive of  little  or  no  harm,  the  bones  tending  to  assume  their  normal 
relation  as  to  shape  with  the  gradual  development  of  the  head.  If, 
however,  a  hemorrhage  has  occurred  beneath  the  skull — inside  the 
cranium — coma,  convulsions,  subsequent  epilepsy,  or  death  may  result. 

In  breech  presentations  the  lower  jaw  may  be  fractured  by  unneces- 
sary traction.  A  fracture  of  the  clavicle  and  humerus,  or  a  separa- 
tion of  the  epiphysis  of  the  humerus,  may  result  from  the  difficulty 
in  bringing  down  the  arm.  The  femur  has  been  fractured  by  improper 
traction  with  the  fingers,  fillet,  or  blunt  hook.  In  other  cases  para- 
plegia may  follow  an  injury  to  the  spine  and  cord  occurring  during 
labor. 

The  important  point  which  such  injuries  emphasize  is  the  necessity 
of  a  careful  examination  of  all  infants  immediately  after  delivery, 
and  this  is  especially  to  be  enjoined  after  all  difficult  labors.  The 
treatment  of  all  such  conditions  is,  of  course,  surgical. 

ASPHYXIA  OF  THE  NEWBORN. 

A  healthy  normal  child  breathes  deeply  almost  immediately  after 
birth,  cries  loudly,  kicks  vigorously,  and  begins  at  once  to  inflate  its 
lungs.  The  upper  lobes  expand  first,  and  the  posterior  portion  of  the 
lower  lobes  last,  the  external  portions  expanding  before  the  deeper 
internal  parts.  At  least  one  or  two  days  pass  before  the  lungs  fully 
expand,  and  in  weak  infants,  or  those  born  prematurely,  it  may  be  one 
or  two  weeks  before  expansion  is  complete.  Owing  to  the  changes  which 
occur  in  the  atelectatic  portions  of  the  lung,  full  expansion  becomes 
more  difficult  as  time  progresses. 

In  asphyxia  of  the  newborn  the  absorption  of  oxygen  and  the  giving 
out  of  carbon  dioxide  are  checked  wholly  or  in  part;  and  this  condition, 
if  severe,  becomes  extremely  dangerous. 

Etiology.- — If  the  respiratory  centre  is  stimulated  before  the  child  is 
born,  attempts  at  breathing  are  induced,  and  asphyxia  from  inhalation 
of  foreign  matter  is  the  result.  The  stimulus  to  breathe  may  be  derived 
from  the  mother  as  the  result  of  a  fall  in  her  blood-pressure  due  to 
hemorrhage,  protracted  labor,  or  to  her  death. 


ASPHYXIA   OF   THE  NEWBORN  113 

An  abnormal  form  of  uterine  contraction,  the  so-called  tetanus  uteri, 
or  any  disease  of  the  heart  or  lungs  in  the  mother  combined  with 
poor  circulation  and  poor  oxygenation  of  her  blood,  will  produce  intra- 
uterine asphyxia  in  the  child.  So  will  any  condition  which  causes 
compression  of  the  umbilical  cord,  as  early  detachment  of  the  placenta 
or  premature  birth,  the  respiratory  muscles  being  weak  and  the 
respiratory  centre  poorly  developed;  or  any  condition  like  cerebral 
hemorrhage,  which  produces  abnormal  intracranial  pressure.  As  the 
carbon  dioxide  in  the  blood  increases  and  the  oxygen  decreases,  the 
respiratory  centre  loses  more  and  more  its  power  to  respond  to  stimula- 
tion, until  finally  no  effort  at  respiration  is  made,  and  it  becomes 
paralyzed.  It  is,  however,  apparently  more  the  lack  of  oxygen  that 
paralyzes  the  respiratory  centre  than  an  increase  of  carbon  dioxide. 

Asphyxia  Cyanotica. — A  child  suffering  from  intra-uterine  asphyxia 
passes  meconium,  and  invariably  shows  a  weakness  in  the  heart 
sounds;  if  the  asphyxia  is  extreme  the  heart's  action  becomes  unusually 
rapid,  and  the  child  is  in  danger  of  death,  a  condition  which  generally 
demands  that  labor  be  terminated  as  soon  as  possible. 

In  asphyxia  cyanotica  the  child's  color  at  birth  varies  from  a  bluish 
tint  to  a  dark  blue.  It  lies  absolutely  still,  its  face  is  swollen,  its  eyes 
are  closed.  The  respirations  are  superficial,  and  the  intervals  between 
them  may  be  much  longer  than  normal.  Mucous  rales  can  often  be 
heard,  or  felt  by  the  hand  on  the  thorax.  The  muscles  preserve  their 
firmness  and  tone,  and  the  heart's  action  is  strong  but  slow.  A  finger 
introduced  into  the  pharynx  to  remove  inspired  material  produces 
reflex  choking.  The  respiratory  movements  can  usually  be  increased 
with  little  difficulty  by  external  applications,  either  hot  or  cold. 

Asphyxia  Pallida. — In  this  form  the  upper  air  passages  are  more  or 
less  completely  blocked  with  mucus.  The  infant  is  very  pale,  its  lips 
are  blue,  and  the  muscles  are  limp  and  relaxed.  Reflex  irritation  is 
abolished,  the  heart  is  rapid  and  weak,  and  the  extremities  are  cold. 
Respiration  is  practically  suspended,  although  the  child  frequently 
gasps  for  breath.  The  temperature  slowly  falls,  the  heart's  action 
becomes  more  feeble,  and  the  child  may  sink  and  die.  In  milder 
cases,  the  respiration  gradually  becomes  better  estabhshed,  the  eyes 
open,  and  the  child's  movements  grow  stronger.  The  skin  becomes 
warm  and  pink,  the  pulse  stronger  and  regular;  coughing  and  vom- 
iting help  to  expel  the  mucus.  The  umbilical  cord  is  soft,  pale,  and 
relaxed. 

Pathological  Anatomy. — The  right  heart  is  distended,  the  blood 
watery,  the  liver  congested.  Hemorrhages  into  the  pia,  pericardium, 
pleura,  and  liver  occur,  also  hemorrhagic  effusions  into  the  serous 
cavities.  There  is  marked  congestion  of  the  lungs,  and  the  upper  air 
passages  and  bronchi  are  filled  with  inspired  matter.  If  the  child  at 
birth  has  made  any  eft'orts  at  respiration,  and  has,  perhaps,  lived  for 
a  short  time,  areas  of  more  or  less  expanded  lung  tissue  are  found, 
which  are  light  in  color  and  elevated  above  the  dark  and  tougher 
atelectatic    portions.      Inspired    materials,    such    as    mucus,    blood. 


114  DISEASES  OF   THE  NEWBORN 

amniotic  fluid,  and  meconium  are  found  in  the  upper  air  passages  and 
large  bronchi;  sometimes  also  in  the  small  bronchi. 

Prophylaxis. — Prophylaxis  includes  the  conduct  of  the  labor  in  such 
a  manner  as  to  prevent,  so  far  as  possible,  the  causes  which  produce 
asphyxia,  and  also  such  care  of  the  mother  during  pregnancy  as  may 
protect  her  from  infections  and  injuries. 

Diagnosis. — Asphyxia,  either  cyanotica  or  pallida,  is  evident  as 
soon  as  the  child  is  born.  The  clinical  picture  of  either  form  is  so 
clear  that  a  diagnosis  can  be  made  immediately.  The  only  question 
which  may  arise  is,  as  to  whether  the  asphyxia  may  be  due  to  a  cerebral 
hemorrhage  instead  of  to  some  impediment  in  the  placental  circulation, 
or  to  material  inspired  into  the  upper  air  passages.  Asphyxia  due  to 
brain  hemorrhage  is  associated  with  a  bulging  fontanelle,  convulsions, 
irregular  respiration,  slow  pulse,  and  stupor,  the  respirations  being 
sufficiently  numerous  to  warrant  some  lessening  of  the  asphyxia. 
Asphyxia  not  due  to  brain  lesions  is  invariably  relieved  by  any 
improvement  in  the  respiratory  rate,  except,  of  course,  in  premature 
or  very  weak  infants,  where  the  respirations  are  fairly  regular,  the 
asphyxia  being  in  these  cases  simply  an  index  of  the  child's  poorly 
developed  nerve  centres  and  muscles. 

Prognosis. — If  treatment  is  prompt  and  energetic,  many  of  the 
apparently  hopeless  cases  are  saved.  When  the  asphyxia  is  asso- 
ciated with  any  lesion  of  the  central  nervous  system,  mental  defects 
or  evidences  of  paralysis  may  develop.  In  asphyxia  due  to  cerebral 
hemorrhage  the  prognosis,  of  course,  depends  upon  the  extent  of  the 
brain  lesion. 

Treatment. — Artificial  respiration  must  be  continued  in  every  case 
until  the  child  breathes  with  sufficient  regularity  to  make  one  feel 
that  this  assistance  is  no  longer  required.  It  is  difficult  to  say  how  long 
one  should  persist  in  artificial  respiration  in  apparently  hopeless  or 
desperate  cases.  Many  children  have  been  saved  by  this  method  who, 
seemingly,  had  little  chance  of  life,  judging  by  their  appearance 
immediately  after  birth.  As  long  as  a  heart  beat  can  be  detected,  it  is 
possible  for  life  to  be  saved. 

The  mucus  and  inspired  materials  that  clog  the  upper  air  passages 
and  bronchi  must  be  removed  as  quickly  as  possible.  The  mouth 
and  pharynx  should  be  wiped  out  with  gauze,  and  the  deeper  mucus 
removed  by  aspiration  through  a  soft  catheter.  Alternate  hot  and 
cold  douches  are  beneficial  in  stimulating  respiration,  or  the  child 
may  be  alternately  plunged  into  hot,  then  cold  water,  always  in 
asphyxia  pallida  beginning  and  ending  with  hot  water.  In  this  form, 
too,  special  efforts  should  be  made  to  keep  the  infant's  body  warm, 
and  the  child  should  be  carefully  watched  for  from  twenty-four  to 
thirty-six  hours  to  see  that  the  asphyxia  does  not  return.  Inhalations 
of  oxygen  are  of  benefit  in  these  cases,  also  small  doses  of  whisky, 
10  drops  every  three  hours,  with  strychnin  ^^^  of  a  grain  hypo- 
dermically,  repeated  in  six  hours. 

If  blood  is  allowed  to  escape  from  the  umbilical  cord  a  portion. 


ASPHYXIA   OF   THE  NEWBORN  115 

at  least,  of  the  carbon  dioxide  is  removed;  and,  in  a  few  reported 
cases,  this  blood  has  been  replaced  with  good  results  by  transfusing 
normal  salt  solution  into  the  umbilical  vein.  Intratracheal  insufflation 
of  oxygen  has  been  performed  with  apparent  benefit.  In  a  doubtful 
case  of  cerebral  injury,  lumbar  puncture  may  help  to  clear  up  the 
diagnosis;  if  the  fluid  removed  is  clear  it  points  to  the  absence  of 
hemorrhage  within  the  skull;  if  blood-tinged,  it  indicates  some  injury 
to  the  central  nervous  system,  and  the  removal  of  the  blood-tinged 
fluid  may  possibly  assist  in  the  treatment. 

Atelectasis. — The  lungs  at  birth  are  normally  in  a  condition  of 
atelectasis,  but  begin  to  expand  at  the  very  first  breath;  the  upper 
portions  being  inflated  first,  and  the  lower  parts  last.  It  is  not  only 
necessary  that  the  lungs  be  inflated  as  soon  after  birth  as  possible, 
but,  once  inflated,  that  they  be  kept  expanded — a  task  not  always 
easy  of  accomplishment  in  weak  and  puny  infants.  The  longer  the 
time  after  birth  that  the  lungs  remain  atelectatic,  the  greater  the 
changes  that  take  place  in  them,  and  the  more  difficult  it  is  for  the 
infant  to  inflate  the  collapsed  portions. 

Etiology. — Atelectasis  is  often  the  result  of  the  same  causes  as  is 
asphyxia,  i.  e.,  tedious  labor,  premature  birth,  inhalation  of  foreign 
materials  before  birth,  and  cerebral  hemorrhages.  It  is  frequently 
seen  in  frail  and  delicate  infants,  and  in  cases  of  hereditary  syphilis. 

Pathological  Anatomy. — If  a  child  with  atelectasis  lives  but  a  day 
or  two,  only  a  small  portion  of  the  anterior  borders  of  the  upper  lobe 
become  expanded,  and  this  portion  may  also  be  emphysematous. 
The  posterior  portion  of  the  lower  lobes  is  the  most  common  seat  of 
atelectasis.  The  unexpanded  portion  is  brownish-red,  very  vascular, 
does  not  crepitate,  and  shows  globular  outlines  on  the  surface  and  on 
section;  it  can  very  easily  be  inflated.  Small  hemorrhages  are  fre- 
quently found  beneath  the  pleura.  Both  lungs  are  usually  involved. 
The  child  may  live  several  weeks,  and  yet  be  quite  atelectatic;  and,  if 
the  condition  persists  a  long  while,  it  is  apt  to  be  associated  with 
pneumonia.  The  right  heart  is  commonly  dilated,  the  liver  and  spleen 
are  enlarged  and  congested,  and  cerebral  hemorrhage,  either  at  the  base 
or  convexity,  is  often  present,  especially  where  there  is  a  history  of 
difficult  labor.  Lung  conditions,  such  as  aplasia,  may  be  noted,  or 
atelectasis  may  be  associated  with  an  enlarged  thymus.  Delicate 
thoracic  walls  and  poorly  developed  respiratory  muscles  favor  the 
non-expansion  of  the  lung. 

Symptoms. — In  atelectasis  the  whole  or  a  part  of  the  lung  remains 
in  the  fetal  state.  The  condition  is  usually  associated  with  asphyxia, 
and  in  relieving  the  asphyxia  we  generally  assist  in  clearing  up  the 
atelectasis  to  a  greater  or  less  extent.  Feeble  and  premature  infants 
do  not  breathe  deeply  enough  fully  to  expand  their  lungs,  and  portions 
remain  atelectatic.  The  respiratory  movements  are  weak  and  apt 
to  be  superficial,  with  irregular  rhythm.  In  severe  cases  of  atelectasis, 
the  cyanosis  is  generally  marked.  As  a  rule,  the  history  is  that  of  a 
moderate  asphyxia  at  birth,  the  infant,  howe\'er,  being  revived  without 


116  DISEASES  OF   THE  NEWBORN 

great  effort.  The  child  is  below  the  norn:;al  weighty  and  frail  and 
delicate,  perhaps  prematiu-e.  It  fails  to  gain  in  strength  or  weight, 
the  hands  and  feet  are  generally  cold,  and  the  temperature  may  be 
subnormal.  The  cry  is  feeble.  From  time  to  time,  there  are  evidences 
of  cyanosis  which  may  be  slight  or  marked;  it  may  develop  suddenly 
without  apparent  cause  and  be  extreme,  even  ending  fatally,  con- 
vulsions often  appearing  before  death. 

It  must  be  borne  in  mind  that  an  atelectatic  child  need  not  neces- 
sarily have  been  asphyxiated  at  birth.  The  child  may  present  no  lung 
symptoms  until  the  final  attack  of  cyanosis  develops.  Many  of  the 
cases  occur  in  puny  delicate  infants,  or  the  prematurely  born,  with 
low  vitality,  and  an  improvement  in  the  atelectasis  is  an  indication  of 
improvement  in  their  general  health.  If  the  child  gains  in  weight 
the  atelectasis  gradually  disappears.  Often  an  excess  of  carbon  dioxide 
— either  small  or  great,  but  persistent — is  present  in  the  blood,  while 
the  amount  of  oxygen  is  subnormal,  thus  causing  paralysis  of  the 
respiratory  centre.  The  infant  is  unnaturally  quiet,  often  drowsy, 
the  face  and  hands  may  be  puft'y,  and  the  temperature  perhaps  sub- 
normal. Breathing  is  irregular  and  slow,  and  on  crying  a  few  rales 
are  heard  at  the  back  and  base  of  the  lungs.  Attacks  of  cyanosis, 
mild  or  severe,  may  develop  without  apparent  cause  or  warning,  and  a 
premature  child  several  weeks  of  age  may  suddenly  become  cyanotic, 
and  develop  dangerous  symptoms,  and  even  death  follow.  In  the  most 
severe  cases  asphyxia  is  marked  at  birth,  the  child  is  only  partially 
revived,  lives  a  few  days  or  hours,  and  dies  with  all  the  evidences  of 
asphyxia,  prostration,  and  coma. 

Diagnosis. — Atelectasis  is  most  common  in  the  posterior  portion 
of  the  lower  lobe  of  the  lung.  Over  this  portion  resonance  is  impaired, 
but,  as  the  collapsed  areas  are  surrounded  by  portions  of  inflated 
lung,  the  impairment  is  not  marked,  the  respiratory  murmur  is  feeble 
and  harsher  than  normal,  and  on  deep  inspiration  rales  are  usually 
heard.  The  cardiac  sounds  may  be  transmitted  more  clearly  than 
is  normal. 

Prognosis. — This  depends  on  the  cause  and  the  treatment.  If  the 
child  improves,  as  shown  by  a  gain  in  weight,  strength,  and  vitality, 
the  chances  are  good.  If  the  cyanosis  tends  to  recur,  with  loss  of 
flesh  and  vitality,  a  subnormal  temperature,  and  cold  hands  and  feet, 
the  prognosis  is  grave. 

Treatment. — A  frail  and  delicate  infant,  especially  if  drowsy  and 
with  irregular  respirations,  must  be  aroused  five  or  six  times  a  day. 
Its  face  may  be  washed  with  hot  and  cold  water  alternatel}^,  or  may 
be  sharply  smacked  with  a  handkerchief  dipped  in  cold  water,  or 
the  abdomen  may  be  slapped  in  a  similar  manner.  If  possible,  the 
infant  must  be  made  to  cry  and  to  take  deeper,  fuller  breaths.  The 
temperature  can  be  maintained  with  hot  water  bottles,  and  the 
cyanosis  combated  with  oxygen  inhalations.  Excessive  handling  is 
bad  for  babies;  but  a  certain  amount  of  it  is  beneficial,  especially 
if  the  baby  is  frail  and  delicate.    Pick  it  up,  rub  it,  change  its  position 


MASTITIS  117 

I'roni  one  side  to  the  otlie>r.  If  allowed  to  lie  a  long  time  in  its  crib, 
as  is  occasionally  the  case  in  asylums  and  hospitals,  a  feeble  delicate 
child  is  apt  to  develop  atelectasis,  and  certainly  recovers  from  it  with 
difficulty.  The  cold  hands  and  feet  should  be  protected  with  mitts 
and  socks.  Breast  milk  is  by  far  the  best  food;  the  breast  may  be 
pumped  out,  and  the  milk  fed  to  the  infant  with  a  dropper,  a  spoon, 
or  a  Breck  feeder. until  the  baby  is  strong  enough  to  nurse.  In  order 
to  keep  up  the  mother's  secretion  of  milk,  another  infant  should, 
if  possible,  be  put  to  the  breast.  For  relief  of  the  cyanosis  artificial 
respiration,  warm  baths,  whisky  internally,  and  oxygen  by  inhalation 
are  recommended. 

MASTITIS. 

There  appears  in  all  children  two  or  three  days  after  birth  a  swelling 
of  the  mammary  glands,  w^hich  increases  gradually,  is  more  marked 
in  some  infants  than  in  others,  and  reaches  its  height  at  about  the 
tenth  day,  then  slowly  subsides,  and  disappears  in  the  third  week. 
The  condition  is  physiological,  and  produces  no  symptoms,  so  far  as 
we  can  judge.  According  to  J.  Halban,  it  is  caused  by  the  presence  in 
the  fetal  and  infant  blood  of  certain  bodies  that  exist  in  the  blood  of 
pregnant  women,  and  are  carried  by  the  placental  circulation  to  the 
blood  of  the  fetus.  At  birth  these  bodies  are  present  in  the  blood 
of  all  children,  boys  and  girls,  and  they  reappear  in  girls  at  puberty, 
and  in  women  during  pregnancy.  Halban  claims  that  they  are  pro- 
duced by  placental  and  chorion  secretions,  and  that  the  swelling  which 
normally  appears  in  the  breasts  of  the  newborn  infant  is  due  to  the 
temporary  existence  in  the  infant's  blood  of  these  bodies,  and  that 
•the  same  secretion  in  the  blood  of  the  mother  stimulates  the  marked 
changes  that  occur  in  her  mammary  glands.  The  infant's  breasts 
after  birth  show  distended  ducts,  hemorrhages,  leukocytes,  and 
prohferated  epithelium — products  similar  to  those  in  the  breasts  of 
Its  mother.  The  baby's  breasts  are  enlarged,  more  or  less  firm,  and  on 
gentle  pressure  a  few  drops  of  milky  fluid  can  be  expressed.  This 
fluid,  chemically  examined,  contains  fat,  milk  sugar,  protein,  salts, 
and  ash.  Microscopically  it  shows  milk  globules,  leukocytes,  and 
colostrum  corpuscles,  and  in  composition  it  is  practically  the  same  as 
colostrum.  Mastitis  developing  in  this  physiologically  enlarged  breast 
manifests  itself  by  enlargement,  with  redness  and  tenderness.  The 
swelling  gradually  increases,  and  unless  checked  may  go  on  to  abscess 
formation.  Loss  of  sleep,  crying,  and  restlessness,  with  vomiting  and 
diarrhea,  are  the  usual  symptoms,  and  high  fever  is  common. 

Etiology. — Squeezing  or  pressing  the  breast  to  express  the  milk  is 
probably  the  most  common  cause  of  mastitis,  and  a  binder,  if  applied 
too  tightly,  may  by  its  continuous  pressure  produce  the  same  result. 
The  tendency  to  inflammation  is,  of  course,  increased  by  the  physio- 
logical activity  and  congestion  normally  present,  particularly  during 
the  second  week  of  life,  when  it  is  greatest.    The  skin  of  the  newborn 


118  DISEASES  OF   THE  NEWBORN 

is  liable  to  infectious  through  the  slightest  injury,  hence  organisms 
effect  an  easy  entrance. 

Bacteria  are  normally  present  in  the  milk  ducts  of  infants,  and  any 
local  condition  which  lowers  the  resistance  of  the  epithelium  permits 
the  migration  of  these  bacteria  with  resulting  inflammation.  Any 
abrasion,  crack,  or  injury  to  the  infant's  nipple,  such  as  might  result 
from  a  too  vigorous  washing  and  first  cleansing  of  the  infant,  can 
easily  become  the  portal  of  entry  for  the  invading  bacteria. 

A  child's  body  should  always  be  kept  absolutely  clean,  and  want  of 
care,  as  a  rule,  is  probably  a  common  cause  for  the  development  of  the 
condition.  In  the  girl  baby,  suppuration  will  necessarily  produce 
more  or  less  destruction  of  normal  glandular  tissue,  and  this  will 
interfere  to  a  greater  or  less  extent  with  the  future  normal  development 
of  the  breasts. 

Prognosis. — A  mild  attack  of  mastitis  is  not  apt  to  make  the  infant 
ill;  if,  however,  the  inflammation  spreads  and  becomes  phlegmonous, 
as  it  may  in  a  delicate  and  frail  infant,  the  condition  may  be  serious. 

Treatment. — Prophylaxis  comprises  the  protection  of  the  breasts 
from  pressure  and  trauma,  and  the  observance  of  abs^olute  cleanliness. 
It  is  never  wise  to  attempt,  even  in  the  gentlest  way,  to  squeeze  out 
the  milk  normally  present.  The  breasts  should  be  carefully  protected 
from  unnecessary  pressure  and  manipulation.  If  inflammation  ap- 
pears a  pad  of  gauze,  kept  wet  with  alcohol  one  part  to  three  parts  of 
water,  and  covered  with  oiled  silk,  should  be  continuously  applied  to 
the  inflamed  area  and  kept  in  place  by  a  loose,  broad  bandage. 

The  infant's  food  should  be  diluted  by  giving  it  a  tablespoonful 
of  water  before  each  nursing,  and  its  bowels  moved  by  a  dessertspoon- 
ful of  castor  oil.  If  pus  forms,  an  incision  should  be  made  parallel 
with  the  direction  of  the  milk  ducts,  and  a  suitable  antiseptic  dressing 
applied.  The  incision  should  be  made  near  the  periphery  of  the  gland 
in  order  to  cut  as  few  milk  ducts  as  possible.  Treatment  is  usually 
successful,  and  the  abscess  heals  in  a  few  days.  The  suction  apparatus 
of  Bier  may  possibly  be  of  service. 

ICTERUS  NEONATORUM. 

Etiology. — This  form  of  jaundice  occurs  in  the  newborn  and  is 
considered  physiological ;  so  far  as  is  known  at  present  it  is  unconnected 
with  any  pathological  condition.  Undoubtedly  it  is  in  some  way 
associated  with  the  liver,  and,  while  there  are  many  theories  as  to  its 
origin,  it  is  probably  due  to  an  active  production  of  bile  immediately 
after  birth;  this,  added  to  the  fact  that  the  capillary  bile  ducts  are 
filled  with  viscid  bile  before  birth,  produces  distention  of  the  capillaries 
in  excess  of  their  emptying  capacity,  and  this  excess  of  bile  is  absorbed 
by  the  blood.  The  disintegration  of  the  maternal  erythrocytes  is 
also  to  a  certain  extent  concerned  in  the  production  of  the  jaundice. 

Pathological  Anatomy. — The  liver  is  found  to  be  only  slightly 
jaundiced  in  small  areas.    The  kidneys  and  spleen  are  normal,  and  the 


ICTERUS  NEONATORUM  119 

coJor  of  the  stools  is  unaffected  1)\-  the  icterus.  ]\iaeroscopic;i,ll\-  the 
urine  does  not  show  the  presence  of  bile,  although  delicate  tests  may 
reveal  bile  pigment,  bilirubin,  and  glycocholic  acid.  In  a  case  of 
icterus  neonatorum  deatli  must,  of  course,  be  caused  by  some  fatal 
disease  or  condition  unconnected  with  the  icterus. 

In  such  instances,  according  to  Orth,  bilirubin  crystals  are  found 
in  the  kidneys,  in  the  blood,  fatty  tissues,  brain,  and  other  organs. 
With  the  exception  of  the  spleen  and  kidneys  almost  all  of  the  organs 
and  tissues  are  jaundiced,  and  this  is  especially  marked  in  the  serous 
membranes,  the  intima  of  the  bloodvessels,  and  the  exudates  and 
transudates.    The  bile  ducts  are  normal. 

Symptoms. — Jaundice  appears  between  the  second  and  fifth  days 
after  birth,  occasionally  later.  It  is  usually  first  seen  on  the  face,  and 
then  spreads  over  the  entire  body.  The  hyperemia  normally  present 
in  the  skin  may  obscure  the  jaundice  for  the  first  twenty-four  hours 
after  its  appearance,  but  pressure  on  the  skin  makes  the  icterus  easily 
recognizable.  The  sclerotic  coat  of  the  eye  is  usually  but  not  always 
yellow,  and  the  mucous  membrane  of  the  mouth  is  also  jaundiced, 
as  is  shown  by  the  yellow  tint  which  appears  after  firm  pressure  upon 
the  buccal  mucous  membrane.  The  pulse  rate  is  normal  in  the  infant 
with  icterus  neonatorum,  and  this  is  also  true  of  older  children  with 
jaundice,  probably  owing  to  the  fact  that  only  small  amounts  of  the 
bihary  acids  are  found  in  the  bile  of  children;  according  to  Jakubowitsch 
glycocholic  acid  is  present  but  taurocholic  is  not.  The  icterus  may  be 
slight  or  very  intense;  it  usually  persists  for  from  four  to  eight  days, 
although  it  may  last  only  for  two  days,  or  may  continue  for  three  weeks. 

If,  after  two  or  three  weeks,  the  jaundice  shows  a  tendency  to  persist 
or  to  deepen,  it  is  unlikely  that  the  disease  is  merely  icterus  neonatorum, 
but  it  is  probably  a  more  serious  form,  the  result  of  either  sepsis  or 
obhteration  of  the  bile  ducts.  The  condition  is  very  common;  if 
carefully  examined  over  50  per  cent,  of  all  children  will  show  more  or 
less  evidence  of  it.  It  is  especially  common  in  premature  children, 
and  the  smaller  the  birth  weight  the  more  intense  is,  as  a  rule,  the 
jaundice.  It  is  claimed  that  it  occurs  more  frequently  in  the  children 
of  primipara  than  of  multipara,  and  early  ligation  of  the  umbilical 
cord  is  said  to  lessen  the  liability  of  its  occurrence.  It  is  probably  a 
physiological  condition  which,  so  far  as  is  known,  does  not  permanently 
harm  the  child,  although  it  is  claimed  that  children  deeply  jaundiced 
are  especially  apt  to  lose  weight  during  the  first  few  days  of  life,  and 
their  subsequent  gain  is  slower.  The  urine  is  usually  normal  in  appear- 
ance, but  is  said  to  contain  increased  amounts  of  urea  and  uric  acid. 
The  jaundice  has  no  effect  on  the  color  of  the  stools. 

Diagnosis. — Jaundice  associated  with  sepsis  does  not  appear  u^itil 
after  the  fifth  or  sixth  day,  it  is  accompanied  by  fever  and  loss  of 
weight,  and  often  by  umbilical  infection,  pneumonia,  meningitis, 
peritonitis,  or  epiphysitis.  Cases  with  congenital  malformations  of  the 
bile-ducts  are  usually,  but  not  always,  jaundiced  at  birth.  The  icterus 
steadily  deepens,  there  is  no  bile  in  the  stools,  the  urine  is  high-colored. 


120  DISEASES  OF   THE  NEWBORN 

and  the  symptoms  continuously  increase  in  se\'erity  until  death  occurs. 
Hemorrhages  under  the  skin  and  in  the  mucous  membranes  are  common. 
In  interstitial  hepatitis,  which  may  be  syphilitic,  the  liver  and  spleen 
are  enlarged,  and  the  jaundice  is  usually  more  intense  than  in  icterus 
neonatorum.  Gall-stones  are  rare  in  children,  but  are  more  common 
in  infancy  than  during  child  life.  Still  reports  15  cases  in  infants, 
in  several  of  whom  the  jaundice  was  marked  at  or  soon  after  birth, 
and  gall-stones  were  found  in  the  ducts.  In  catarrhal  jaundice  icterus 
of  the  conjunctiva  is  noted  as  the  first  symptom  before  there  is  any 
evidence  of  jaundice  in  the  skin.    The  urine  is  invariably  high-colored. 

Prognosis. — This  form  of  jaundice  in  itself  is  never  dangerous,  but 
a  coexisting  condition,  such  as  premature  birth  or  atelectasis,  may 
of  course  influence  the  prognosis. 

Treatment. — The  disease  requires  no  special  treatment,  and,  if  no 
complications  arise,  is  self-limited.  Care  as  to  diet,  fresh  air,  and 
general  hygiene  is  important  in  all  well-marked  cases  of  jaundice  in 
infants,  owing  to  the  fact  that  the  child  may  be  premature,  and  have  a 
tendency  to  regain  the  initial  loss  in  weight  more  slowly  than  those  not 
affected  with  icterus. 

ACUTE  SEPTIC  INFECTION  OF  THE  NEWBORN. 

This  includes  all  acute  infections  in  the  newborn  produced  by 
bacteria.  The  infection  may  be  local,  as  in  the  eye,  mouth,  umbihcus, 
and  vagina,  or  bacteria  may  enter  the  circulation  and  produce  a  severe 
or  fatal  septicemia  or  pyemia. 

Etiology. — Septic  infection  of  the  newborn  was  formerly  common 
in  large  maternity  hospitals,  and  to  a  less  degree  in  private  practice; 
but  as  a  result  of  the  general  adoption  of  asepsis  the  number  of  cases 
has  largely  decreased.  The  newborn  infant  is  especially  hable  to 
infection  owing  to  the  open  wound  at  the  umbilicus,  and  to  the 
abrasions  of  the  skin  and  mucous  membranes  which  may  happen  at 
birth.  Moreover,  its  power  of  resistance  to  infection  is  very  slight, 
the  inability  to  resist  or  cast  off  septic  infections  being  probably  due 
to  the  lessened  antibodies  and  other  protective  substances  in  the 
blood,  as  well  as  to  the  comparatively  undeveloped  condition  of  the 
lymphatics  and  spleen. 

Breast-fed  babies  are  less  liable  to,  and  resist,  infection  better 
than  bottle-fed  babies,  the  vital  principles  of  breast  milk  probably 
being  one  of  the  factors  contributing  to  this  result.  Frail  and  prema- 
ture infants,  too,  are  not  only  more  susceptible  to  septic  infection  but 
less  able  to  resist  its  progress.  The  infection  in  the  large  majority  of 
cases  comes  from  without;  the  main  portals  of  entry  are  the  umbilicus, 
the  skin  and  mucous  membranes,  and  the  respiratory  and  gastro- 
intestinal tracts.  Many  cases  are  umbilical  in  origin,  even  when  there 
is  apparently  no  local  evidence  of  infection  at  the  navel.  Infection 
of  the  thrombi  in  the  umbilical  veins  readily  occurs  owing  to  their 
proximity  to  the  bacteria  normally  present  and  active  in  the  necrotic 


ACUTE  SEPTIC  INFECTION  OF  THE  NEWBORN  121 

processes  wliieh  result  in  the  separation  of  the  unil)ilieal  stnmp.  If 
se])tic  phlebitis  follows,  <i;eneral  sepsis  may  develop  and  involve  one 
or  many  of  the  organs  of  the  body ;  in  these  infants  the  liver  is  especially 
liable  to  infection  because  so  much  of  the  blood  immediately  passes 
through  it.  Septic  infection  may  be  conveyed  through  any  abrasion 
of  the  skin  or  mucous  membrane,  or  infected  materials  may  be  inhaled 
or  swallowed  either  just  before  or  after  delivery.  Sepsis  may  be 
produced  by  many  different  bacteria;  most  commonly  by  the  staphy- 
lococcus pyogenes  albus  and  aureus,  the  streptococcus,  the  pneumo- 
coccus,  the  colon  bacillus,  the  bacterium  lactis  aerogenes,  the  bacillus 
enteridis,  the  bacillus  pyocyaneus,  or  the  proteus  group,  and,  less 
often,  by  the  meningococcus,  the  influenza  bacillus,  the  gonococcus, 
and  the  bacillus  of  Friedlander.  Modern  aseptic  treatment  of  the 
cord  has,  however,  lessened  the  number  of  these  cases,  as  the  majority 
of  infants  are  infected  from  external  sources. 

Bacteria  are  often  air-borne,  especially  in  hospitals.  They  are 
found  in  breast-milk  when  the  breast  itself  may  apparently  be  normal ; 
bacteria  may  enter  the  milk  ducts  from  without  through  the  skin,  or 
an  abscess,  ulcer,  or  fissure  may  exist.  Judging  clinically,  this  milk 
apparently  seldom  in  any  way  injures  the  infant.  Infection  is  less 
likely  from  human  than  from  cow's  milk;  bacteria  are  present  in  both, 
but  are,  of  course,  less  numerous  and  less  apt  to  be  pathogenic  in  human 
than  in  cow's  milk. 

The  nurse  may,  perhaps,  be  the  carrier  of  infection  from  the  mother 
or  from  another  child,  or  it  may  be  carried  by  the  physician  by  means 
of  instruments,  dressings,  or  unclean  hands.  Soiled  clothing  and 
dirty  bathing  water  are  not  infrequent  sources  of  infection  through  the 
injured  or  normal  skin  of  the  infant.  The  bathing  of  infants  before 
the  navel  has  healed  apparently  increases  the  chances  of  infection. 
Of  1420  infants  tubbed  during  the  period  preceding  the  healing  of  the 
umbilicus,  infection  occurred  in  18  per  cent.,  whereas  in  1692  infants 
not  tubbed  only  8  per  cent,  were  infected. 

The  epithelial  lining  of  the  gastro-intestinal  and  respiratory  tracts 
in  the  infant  offers  little  resistance  to  the  invasion  of  bacteria  and, 
as  has  been  previously  stated,  the  baby's  ability  to  produce  antibodies 
or  protective  substances  is  slight.  Infection  may  come  from  within 
and  the  newborn  be  septic  at  birth,  the  infection  occurring  through 
the  placental  circulation.  The  mucous  membrane  of  the  mouth  is 
also  often  the  seat  of  infection. 

Pathological  Anatomy. — In  all  severe  cases  hemorrhages  and  degen- 
erative changes  take  place  in  the  parenchyma  of  the  heart,  liver,  and 
kidneys.  Hemorrhages  occur  in  almost  all  of  the  organs  of  the  bodj-, 
as  well  as  in  the  skin,  the  mucous  membrane,  and  in  the  membranes 
of  the  brain,  especially  the  dura,  but  only  occasionally  in  the  brain 
substance.  The  latter  is  often  edematous  and  congested.  In  the 
lungs  bronchopneumonia  and  atelectasis  are  often  found  to  exist, 
and  septic  emboli  may  produce  infarcts  or  small  abscesses;  while 
degenerative  changes,  fatty  in  nature,  are  found  in  Buhl's  disease. 


122  DISEASES  OF   THE  NEWBORN 

The  pleura,  often  shows  ;i  i)iiruleiit  or  serijfihriiioiis  exii(Uite.  Multiple 
abscesses  may  develop  in  the  liver.  The  spleen  may  enlarge,  and  in- 
flammation of  the  mucosa  of  the  gastro-intestinal  tract  may  exist. 
As  a  rule,  the  peritoneum  is  inflamed  only  in  those  cases  where  the 
infection  has  entered  by  the  umbilicus.  The  kidneys  are  always 
involved,  the  lesion  being  usually  either  parenchymatous  or  fatty 
degeneration  with  necrosis  of  the  renal  epithelium  and  involvement 
of  the  kidney  pelvis.  Periostitis,  osteomyelitis,  and  arthritis  may 
be  present.  Umbilical  phlebitis  and  arteritis  commonly  coexist  with 
umbilical  infection.    Gastro-enteritis  may  also  be  found. 

Symptoms. — The  symptoms  of  septic  infection  in  the  newborn  vary 
greatly,  according  to  the  location  of  the  portal  of  entry,  the  severity, 
of  infection,  the  resistance  offered  by  the  infant,  and  whether  the  child 
was  born  prematurely  or  at  full  term.  In  a  large  majority  of  cases  the 
symptoms  are  severe  and  the  baby  seriously  ill,  but  they  may  be  mild 
and  localized;  as,  for  example,  an  inflammation  in  the  skin  or  joints,  or 
a  slight  infection  of  the  umbilicus.  Inasmuch  as  the  symptomatology 
varies  so  much  in  dift'erent  infants,  a  better  idea  of  the  clinical  aspect 
can  be  obtained  by  studying  the  symptoms  separately  than  from 
individual  cases. 

Tein-peratiire. — The  temperature  is  very  variable;  it  may  be  quite 
high,  only  moderate,  or  even  subnormal.  No  fixed  temperature  is 
typical.  It  may  fluctuate  between  wide  limits.  The  most  common 
temperature  chart  is  one  that  shows  high  fever,  103°  to  105°  F.,  with, 
a  drop  each  day  nearly  to  or  below  normal.  This  continues  for  a 
few  days,  after  which,  with  the  rapidly  increasing  weakness  of  the 
child,  it  continues  normal  or  subnormal  with  more  or  less  irregular 
fluctuations. 

The  Skin. — The  skin  is  decidedly  jaundiced,  especially  in  umbilical 
infection,  the  marked  changes  that  occur  in  the  blood  being  a  factor 
in  its  production.  Cyanosis  may  be  noted  in  the  lips,  hands,  and 
feet,  and  there  may  be  swelling  of  the  feet  and  pretibial  edema. 

Hemorrhages. — Hemorrhages  are  very  common,  and  form  a  dis- 
tressing and  dangerous  symptom.  They  may  occur  from  the  umbilicus, 
bowel,  stomach,  or  any  mucous  surface,  or  may  be  noted  as  large  or 
small  purpuric  rashes  in  the  skin.  Large  areas  of  skin  may  undergo 
necrosis  as  a  result  of  infection  from  without,  while  a  deeper  necrosis 
may  produce  extensive  bed-sores. 

The  Mouth. — Inflammation,  either  deep  or  superficial,  may  appear 
in  the  mucous  membrane  of  the  mouth,  and  blood  may  ooze  from  cracks 
and  fissures  in  the  lips.  O.  Kneise  claims  that  in  97.5  per  cent,  of  a 
large  number  of  infants  examined  bacteria  were  abundant  in  the 
mouth  at  birth.  Staphylococci  and  streptococci  were  particularly 
common  and  virulent.  The  bacteria  evidently  entered  the  mouth 
either  before  or  immediately  aftfer  labor.  This  is  probably  a  frequent 
cause  of  septic  oral  infection. 

The  Lungs. — The  lungs  are  more  or  less  involved  in  all  cases. 
Bronchitis  is  almost  invariably  present,  bronchopneumonia  is  a  com- 


ACUTE  SEPTIC  INFECTION  OF   THE  NEWBORN  123 

iijon  comi)li("ili<)n,  wliik-  pleurisy,  and  osperially  (Mninenia,  are  not 
rare.  The  re.spi ration  is  often  rapid  and  superficial,  and  the  respiratory 
symptoms  may  be  the  most  prominent  and  most  serious. 

The  Heart. — Pericarditis  is  quite  common,  and  is  usually  secondary 
to  inflammation  of  the  pleura  or  the  anterior  mediastinum.  Endo- 
carditis is  seen  less  frequently. 

The  Kidneys. — As  a  rule,  the  urine  contains  albumin,  casts,  leuko- 
cytes, bile  pigment,  and  perhaps  hemoglobin  in  solution. 

The  Gasfro-intestinal  Tract. — The  gastro-intestinal  tract  is  usually 
involved.  Vomiting  and  diarrhea  are  common,  and  in  some  cases 
the  sepsis  produces  the  typical  symptoms  of  gastro-enteritis.  The 
vomitus  may  be  green  or  of  a  brownish  tint,  or  may  contain  blood. 
The  stools  are  frequent,  thin,  greenish  or  brownish,  or  may  be  red  or 
black  from  blood.  The  abdomen  may  be  greatly  distended.  Intestinal 
paralysis  may  occur,  and  if  associated  with  abdominal  tenderness 
and  pain  usually  points  to  peritonitis,  the  probability  of  which  is 
increased  in  umbilical  infection. 

2'he  Bones  and  Joints. — The  bones  and  joints  may  show  periostitis 
or  osteomyelitis,  the  hips  and  shoulders  being  especially  likely  to  be 
involved.  If  there  is  restricted  motion,  tenderness  on  pressure,  local 
swelling,  and  pain  on  moving  the  joint,  this  diagnosis  is  warranted. 

MeniJigitis. — Meningitis  of  the  acute  purulent  type  may  exist. 
The  exudate  is  usually  extensive,  and  may  be  associated  with  menin- 
geal hemorrhages  or  small  multiple  abscesses.  Stupor,  convulsions, 
paralysis,  and  bulging  of  the  anterior  fontanelle  are  common  symp- 
toms. Lumbar  puncture  will  confirm  the  diagnosis.  The  child  is  often 
dull  and  drowsy,  and  may  show  irregular  tremors  or  twitchings.  If 
inflammation  or  hemorrhages  exist  in  the  central  nervous  system,  a 
corresponding  paralysis  will  be  observed. 

Diagnosis. — If  there  is  local  evidence  of  infection  at  the  umbilicus; 
associated  with  irregular  fever,  jaundice,  rapid  wasting,  involvement 
of  the  gastro-intestinal  and  respiratory  tracts,  or  hemorrhages,  the 
diagnosis  can  be  made  with  certainty.  But  when  the  child  presents  no 
visible  external  portal  of  entry,  and  the  symptoms  resemble  those  of 
acute  gastro-enteritis,  pneumonia,  or  meningitis,  it  is  often  difficult 
to  decide  whether  acute  septic  infection  is  present  or  not.  The  milder 
cases  of  gastro-enteritis  running  a  slow  course  must  be  difterentiated 
from  the  ordinary  feeding  case.  Blood  cultures  assist  in  doubtful 
cases  by  demonstrating  the  presence  of  bacteria  in  the  circulation.  A 
negative  culture,  however,  does  not  necessarily  prove  that  the  infant 
is  not  sufl'ering  from  septic  infection,  as  a  considerable  number  of 
cases  of  septic  infection  show  no  bacteria  in  the  l^lood  during 
fife. 

Prognosis. — The  mild  cases  recover;  most  of  them,  unfortunately, 
are  of  the  severe  type,  and  end  in  death.  The  prognosis  depends  upon 
the  seat  and  severity  of  infection,  the  local  or  general  involvement  of 
the  body  in  the  septic  invasion,  the  question  whether  the  child  was 
prematurely  born  or  not,  and  its  vitality. 


124  DISEASES  OF   THE  NEWBORN 

Prophylaxis. — Tlie  newborn  infant  slionld  !)e  cared  for  under  tlie 
most  rigid  laws  of  modern  asepsis.  The  umbilicus  should  be  treated 
as  an  open  wound,  and  dressed  accordingly.  In  hospitals  and  other 
institutions  each  infant  should  have  its  individual  thermometer,  basin, 
cotton,  and  its  own  mouth-wash  prepared  in  a  separate  jar.  The 
clothing  should  be  changed  often,  and  kept  scrupulously  clean.  The 
breasts  of  the  mother  should  be  carefully  cleansed  just  prior  to  nursing, 
and  all  feeding  bottles  should  be  regularly  sterilized.  Incubators 
for  premature  infants  should  be  thoroughly  disinfected  after  being 
occupied,  and  only  those  used  that  insure  a  constant  supply  of  fresh 
air.  A  child  should  not  be  cared  for  by  a  nurse  who  is  in  attendance 
upon  a  septic  mother. 

Treatment. — The  child's  nutrition  should  be  kept  at  as  high  a 
standard  as  possible.  Breast  milk  is,  of  course,  the  best  nourishment, 
and  the  mother's  nipples  should  be  carefully  cleansed  before  and  after 
each  nursing.  If  the  child  refuses  to  nurse,  it  should  be  fed  breast- 
milk  with  a  spoon,  medicine  dropper,  or  Breck  feeder.  The  child 
should  be  kept  in  a  room  where  there  is  fresh,  moving  air.  Whisky 
in  15  drop  doses  should  be  given  every  two  hours.  Infusion  of  digitalis, 
TTlxx,  every  four  hours,  or  camphorated  oil,Tn,vj,  given  hypodermically 
three  times  a  day,  will  be  of  service  as  a  heart  tonic.  All  symptoms 
of  severe  type  should  be  treated  as  they  arise.  Any  infectious  condition 
of  the  mouth  should  receive  early  and  careful  appropriate  local  treat- 
ment. In  all  cases  of  septic  infection  the  umbilicus,  even  if  apparently 
healthy,  should  be  washed  daily  with  a  weak  antiseptic  solution, 
and  if  there  is  pus  in  or  around  the  umbilicus  an  incision  should  be 
made,  the  pus  evacuated,  and  the  abscess  thoroughly  washed  out 
with  1  to  6  peroxide  of  hydrogen  solution,  or  1  to  2000  bichloride  of 
mercury  solution,  and  a  sterile  dressing  applied.  If  an  abscess  forms, 
at  any  other  place,  it  should,  if  possible,  be  opened,  and  all  lesions  of  the 
skin  or  mucous  membrane  should  be  promptly  and  carefully  treated. 
Periostitis  and  osteomyelitis  should  receive  early  surgical  treatment. 
Cases  of  meningitis  should  be  treated  according  to  the  indications  given 
under  meningitis,  the  clinical  diagnosis  being  confirmed  by  a  lumbar 
puncture. 

DISEASES  OF  THE  UMBILICUS. 

Disease  of  the  umbilicus  may  be  local  or  may  become  general  by 
the  spread  of  the  infection  through  the  umbilical  veins.  Normally  the 
umbilical  stump  desiccates  and  drops  off  in  about  five  or  six  days, 
although  in  frail  and  premature  children  this  may  not  happen  until 
several  days  later. 

Omphalitis. — The  first  symptoms  are  usually  noticed  on  or  after 
the  sixth  day.  An  inflammation  appears  at  the  navel,  and  spreads 
more  or  less  over  the  surrounding  abdominal  wall.  The  folds  of  the 
navel  become  swollen  and  edematous,  and  considerable  pus  usually 
forms.  The  abdominal  veins  become  enlarged,  lymphangitis  may 
develop,  and  also  cellulitis  of  the  abdominal  wall  surrounding  the 


DISEASES  OF   THE    UMBILICUS  125 

umbilicus  which  may  end  in  abscess,  gangrene,  or  infection  of  the 
umbiHcal  vessels.  In  many  instances  the  affection  is  purely  local, 
and  the  case  ends  in  recovery;  if,  however,  the  umbilical  veins  become 
infected,  the  condition  is  very  dangerous. 

Treatment. — As  the  cause  is  almost  invariably  an  infection  of  the 
umbilicus  at  or  after  birth,  aseptic  treatment  of  the  cord  at  birth  and 
its  subsequent  care  are  absolutely  essential  in  every  case.  This  includes 
asepsis  as  regards  the  mother,  nurse,  and  physician.  Many  physicians 
insist  that  the  child  be  kept  in  a  separate  room  from  its  mother  during 
the  first  two  weeks;  this  is,  of  course,  always  advisable  if  she  is  septic. 
If  an  umbilical  abscess  forms  it  should  be  freely  opened  and  dressed 
aseptically.  The  child  should  be  well  nourished  with  breast  milk, 
and  given  15  drops  of  whisky  every  two  hours. 

Gangrene  of  the  Cord. — Gangrene  of  the  cord  of  the  moist  variety 
is  not  uncommon.  The  stump,  wholly  or  in  part,  becomes  moist, 
swollen,  and  dark,  with  a  discharge  of  offensive  odor.  When  the  gan- 
grenous mass  sloughs,  it  leaves  an  unhealthy  umbilical  stump.  Any- 
thing which  tends  to  keep  the  cord  moist  favors  the  development 
of  this  condition.  Under  local  aseptic  treatment  the  disease  usually 
terminates  favorably.  All  oils,  ointments,  or  wet  umbilical  dressings 
should  be  avoided. 

Gangrene  of  the  Umbilicus. — This  is,  fortunately,  rather  a  rare 
condition,  and  is  seldom  seen  except  in  feeble  and  premature  infants. 
It  may  develop  without  previous  local  lesion,  or  may  follow  some  of  the 
more  common  forms  of  umbilical  infection.  It  usually  appears  between 
the  seventh  and  twentieth  days.  The  gangrenous  area  involves  the 
skin,  adipose  tissue,  and,  perhaps,  the  underlying  muscles ;  it  may  even 
perforate  into  the  abdominal  cavity,  and  involve  the  wall  of  the 
intestine.  Severe  umbilical  hemorrhage  will  indicate  that  the  gangrene 
has  perforated  the  umbilical  vessels.  A  few  cases  end  in  recovery, 
the  gangrenous  tissue  sloughing  off,  and  granulations  forming  at  the 
edges  of  the  necrotic  area.  Most  of  the  cases  terminate  fatally.  The 
infant  rapidly  becomes  exhausted  and  profoundly  toxic,  and  dies  in 
coma,  greatly  emaciated. 

Treatment. — If  possible,  the  gangrenous  tissue  should  be  removed 
with  the  cautery,  the  cauterization  extending  beyond  the  gangrenous 
area.  If  the  condition  is  recognized  early,  this  treatment  offers  some 
hope  of  cure.  If,  however,  the  child  is  premature,  frail,  or  profoundly 
toxic,  and  the  gangrene  is  extending,  it  is  better  to  omit  the  use  of  the 
cautery,  and  apply  hot,  wet,  antiseptic  dressings  locally. 

Umbilical  Hemorrhage. — The  cord  may  have  been  imperfectly 
Ugated,  it  may  have  fallen  off  too  early,  or  the  hemorrhage  may 
result  from  necessary  or  unnecessary  manipulation  of  the  umbilicus. 
In  all  cases  of  hemorrhage  due  to  the  above  causes  the  bleeding  is 
slight,  transient,  and  devoid  of  danger.  Unless  sepsis  or  some  local 
disease  of  the  navel  is  present  a  profuse  spontaneous  umbilical  hemor- 
rhage is  rare,  as  the  arterial  blood-pressure  falls  very  materially  after 
birth  as  soon  as  the  pulmonary  circulation  is  established,  and  after 


126  DISEASES  OF   THE  NEWBORN 

ligation  of  the  cord  the  contraction  of  the  walls  of  the  arteries  tends  to 
check  hemorrhage  by  the  partial  closure  of  the  lumen  of  the  vessels. 
In  fact,  the  normal  fall  in  the  blood-pressure  and  the  contractility  of 
the  arterial  coats  would,  in  the  large  majority  of  newborn  infants, 
prevent  a  fatal  umbilical  hemorrhage,  although  in  asphyxia,  atelectasis, 
prematurity  of  birth,  and  congenital  heart  disease,  a  higher  blood- 
pressure  exists.  Bleeding  may  take  place  from  the  umbilical  arteries 
as  they  emerge  from  the  body,  but  this  is  an  uncommon  form  of 
umbilical  hemorrhage,  which  is  seen  only  after  detachment  of  the  cord; 
it  occurs  from  the  fourth  to  the  fifteenth  day. 

In  the  large  majority  of  cases  of  umbilical  hemorrhage  the  bleeding 
takes  place  from  the  surface  of  the  umbilicus,  the  blood  simply  oozing 
out  from  the  small  vessels  in  and  around  the  navel ;  it  may  occur  before 
or  after  the  cord  has  fallen.  The  amount  of  blood  lost  is  usually  large, 
and  the  hemorrhage  may  be  more  or  less  continuous  for  days,  often 
ending  fatally;  the  mortality  is  over  75  "per  cent. 

The  cause  in  most  cases  is  a  septic  infection,  and  umbilical 
hemorrhage  is  simply  one  of  the  varieties  of  hemorrhage  associated 
with  this  condition.  Sometimes  hereditary  syphilis  causes  the  hemor- 
rhage, and  a  careful  inquiry  should  be  made  into  the  family  history, 
especially  as  it  is  a  well-recognized  fact  that  syphilis  causes  definite 
changes  in  the  bloodvessels.  Umbilical  hemorrhage  as  a  symptom  of 
hemophilia  is  extremely  rare. 

Treatment. — Bleeding  from  the  cord  may  be  controlled  by  a  broad, 
firm  ligature.  Slight  bleeding  from  the  umbilicus  may  be  checked 
by  compresses  moistened  in  adrenalin  solution,  1  to  1000,  or  by  a 
suture  of  the  umbilicus.  In  some  cases  gelatin  in  four  dram  doses, 
carefully  sterilized  and  injected  under  the  skin,  and  repeated  in  eight 
hours  if  necessary,  has  been  used  with  more  or  less  success.  The  general 
treatment  of  septic  infection  should  be  carried  out  as  indicated  under 
that  heading. 

HEMORRHAGE  IN  THE  NEWBORN. 

Hemorrhagic  Disease  of  the  Newborn. — In  the  newborn  hemorrhage 
is  usually  a  symptom  of  infection.  It  may  be  hetero-infection  or  auto- 
infection,  although  the  former  is  much  more  common  than  the  latter. 
While  sepsis  is  accepted  as  being  the  most  common  cause  of  hemor- 
rhage, some  cases  are  midoubtedly  due  to  syphilis.  In  both  sepsis 
and  syphilis  hemorrhage  is  usually  but  one  of  a  number  of  symptoms, 
and  the  bleeding  is  generally  not  profuse.  The  more  closely,  however, 
these  cases  of  hemorrhage  are  studied,  the  more  evident  it  becomes 
that  sepsis  is,  as  a  rule,  the  underlying  cause.  This  applies  also  to 
those  cases  where  hemorrhage  may  be  the  main,  or  is,  in  fact,  the  only 
symptom.  To  some  extent  at  least,  the  bleeding  usually  depends  upon 
some  abnormal  conditions  present  in  the  substances  associated  with 
blood  coagulation.  Under  this  heading  spontaneous  hemorrhages 
alone  are  considered.  A  few  only  of  the  hemorrhages  that  occur  in 
the  first  few  days  of  life  are  due  to  hemophilia. 


HEMORRHAGE  IN   THE  NEWBORN  127 

Hemophilia  is  very  much  more  common  in  boys  than  in  girls,  the 
proportion  being  as  thirteen  to  one,  whereas  hemorrhage  in  the  new- 
born is  about  as  common  in  the  female  as  in  the  male,  and  the  study 
of  a  large  number  of  histories  of  hemophiliacs  does  not  show  that  they 
were  subject  to  hemorrhage  in  the  first  few  days  of  life.  The  bleeding 
rarely  continues  longer  than  a  few  days  or  weeks,  and  the  strong  and 
healthy  child  is  as  liable  to  hemorrhage  as  the  delicate  or  premature. 
The  disease  resembles  an  acute  infectious  process  in  that  it  runs  a 
self-limited  course  and  ends  in  either  death  or  complete  recovery. 
The  hemorrhages  are  especially  apt  to  occur  from  mucous  membranes, 
as  the  mouth,  umbilicus,  or  gastro-intestinal  tract;  less  commonly 
in  the  meninges  of  the  brain,  abdominal  cavity,  pleurae,  lungs,  thymus 
gland,  and  suprarenals;  it  may  also  be  subcutaneous.  While  it  is 
usually  spontaneous,  it  may  also  follow  a  slight  bruise,  or  may  occur 
over  areas  of  pressure,  as  the  occiput,  the  back,  and  the  sacrum.  ]\Iore 
cases  occur  in  maternity  hospitals  than  in  private  practice.  The  disease 
ordinarily  runs  its  course  in  from  one  to  four  days,  occasionally  in 
seven  to  nine.  The  hemorrhage  usually  appears  between  the  second 
and  seventh  days,  rarely  after  the  fifteenth  day,  and  is  often  the  first 
sign  of  the  disease.  The  amount  of  blood  lost  is  usually  not  great, 
but  a  slow  oozing  persists,  and  from  the  onset  of  the  bleeding  the  infant 
is  markedly  prostrated.  A  moderate  fever  is  quite  common,  although 
the  temperature  may  be  normal  or  subnormal.  At  autopsy  no  definite 
pathological  changes  are  found  to  account  for  the  hemorrhage,  but 
gastric  and  duodenal  ulcers  have  been  noted  in  a  few  cases.  Blood 
cultures  have,  as  yet,  thrown  no  light  upon  the  etiology.  That  the 
disease  is  due  to  different  forms  of  infection  is,  however,  the  general 
belief,  although  in  the  first  week  or  two  of  life  the  marked  changes 
occurring  in  the  blood,  the  weakness  of  the  walls  of  the  bloodvessels, 
and  the  change  from  intra-  to  extra-uterine  circulation  are  factors 
that  certainly  predispose  the  infant  to  hemorrhage.  If  the  bleeding 
is  from  the  nose  alone,  hereditary  syphilis  should  be  suspected. 

The  prognosis  is  poor,  the  mortality  being  about  75  per  cent. 

Treatment. — To  accomplish  anything  treatment  should  be  prompt. 
In  hemorrhage  from  the  stomach  or  bowel  a  5  or  10  per  cent,  solution 
of  gelatin  may  be  given  in  large  amounts  by  the  mouth.  Only  well- 
sterilized  gelatin  should  be  used;  the  English  gelatin  is  the  safest, 
as  the  commercial  product  often  contains  the  tetanus  bacillus.  It  may 
also  be  used  subcutaneously,  4  drams  (15  c.c.)  of  a  10  per  cent,  solu- 
tion being  the  usual  dose.  Adrenalin,  1  to  1000  solution,  is  valuable 
if  applied  locally  on  gauze,  and  for  gastro-intestinal  hemorrhage  adre- 
nalin by  the  mouth  in  2-grain  doses  may  be  given  every  three  hours. 

Transfusion  of  blood  is  a  valuable  remedy,  and  should,  when  pos- 
sible, be  resorted  to  in  all  severe  cases.  In  the  hands  of  the  experi- 
enced surgeon  it  is  not  as  difficult  an  operation  as  many  would  lead  us 
to  suppose,  and  recent  improvement  in  technic  has  made  it  more 
easy  of  accomplishment.  Next  to  transfusion,  injections  ol  sterile 
normal  human  blood  serum  offer  the  greatest  hope  of  saving  the  infant's 
life.     The  blood  should  be  withdrawn  and  kept  under  absolutely 


128  DISEASES  OF   THE  NEWBORN 

aseptic  conditions;  5^  drams  (20  c.c.)  of  the  serum  should  be  injected 
subcutaneously  every  six  to  eight  hours  as  long  as  the  hemorrhage 
persists.  Improvement  in  the  child's  general  condition  is  usually 
noted  immediately  after  the  transfusion  or  serum  administration, 
and  the  bleeding  is  often  checked  in  twenty-four  to  forty-eight  hours. 

Normal  horse  serum  may  be  used  if  transfusion  of  human  blood 
serum  is  impracticable.  It  should  be  injected  subcutaneously  in  doses 
of  2|  drams  (10  c.c),  and  repeated  every  eight  to  twelve  hours  if  no 
improvement  is  apparent.  If  the  infant  has  suffered  from  a  profuse 
hemorrhage,  transfusion  of  blood  or  saline  solution  is  the  best  treat- 
ment. Whole  blood  injections  are  simple  and  easy  of  accomplishment. 
Four  drams  (15  c.c.)  of  blood  are  withdrawn  by  a  syringe  from  a  vein 
in  the  donor's  forearm,  and  immediately  injected  subcutaneously  into 
the  infant;  later,  blood  serum  or  transfusion  can  be  employed,  or  the 
whole  blood  injections  can  be  repeated  every  eight  to  twelve  hours. 
Diphtheria  antitoxin,  owing  to  its  being  so  readily  obtained,  may  be 
used  instead  of  human  or  horse  serum.  Lactate  of  calcium,. in  5-grain 
doses  every  four  hours,  is  of  benefit  in  some  cases,  while  breast-milk 
and  also  whisky,  20  drops  every  two  hours,  tend  to  increase  the 
child's  resistance. 

Acute  Fatty  Degeneration  of  the  Newborn  (Buhl's  Disease). — The 
symptoms  in  this  condition  are  associated  with  fatty  changes  in  the 
liver,  kidneys,  and  heart,  and  hemorrhages  are  often  found  in  these 
organs  at  autopsy.  The  liver  and  spleen  are  enlarged,  and  jaundice 
is  a  common  symptom.  The  child  is  born  asphyxiated,  and  is  with 
difficulty  made  to  breathe.  Hemorrhages  occur  from  the  umbilicus, 
the  blood  oozing  from  the  surface  of  the  navel.  There  are  also  hemor- 
rhages from  the  stomach,  bowel,  and,  in  some  cases,  from  the  mouth, 
conjunctiva,  and  nose.  Profuse  hemorrhages  beneath  the  skin  are 
common,  and  there  may  be  considerable  edema.  The  temperature  is 
normal.  The  disease  is  rare,  causes  profound  depression,  runs  a  rapid 
course,  and  usually  terminates  fatally  in  a  week  or  two.  It  is  undoubt- 
edly due  to  septic  infection,  the  portal  of  entry  in  the  majority  of 
cases  probably  being  through  the  umbilicus. 

Epidemic  Hemoglobinuria  (Winckel's  Disease). — This  affection 
occurs  in  the  first  few  days  of  life,  its  special  symptoms  being  cyanosis, 
jaundice,  and  hemoglobinuria. 

Etiology. — It  is  undoubtedly  due  to  infection,  and  the  cases  reported 
by  Winckel  occurred  as  an  epidemic  in  an  institution;  the  infection 
was  probably  conveyed  through  bathing  or  drinking  water.  At 
autopsy  the  colon  bacillus  and  streptococcus  have  been  found  in  the 
blood  and  internal  organs  in  a  few  cases. 

Pathological  Anatomy. — While  all  the  evidence  points  to  septic 
infection  of  the  newborn,  still  the  umbilicus  and  the  umbilical  vessels 
are  normal.  The  spleen  is  swollen  and  contains  much  blood  pigment. 
The  kidneys  are  enlarged,  the  tubules  filled  with  hemoglobin  crystals. 
Minute  hemorrhages  are  seen  in  almost  all  of  the  organs,  while  larger 
amounts  of  blood  mav  be  found  in  the  stomach,  bowel,  liver,  and  pleura. 


HEMORRHAGE  IN   THE  NEWBORN  129 

The  mesenteric  glands  and  Peyer's  patches  are  swollen,  and  there  is 
fatty  degeneration  of  the  liver  and  other  internal  organs. 

Symptoms. — At  birth  the  infant  is  apparently  healthy  and  normally 
developed.  Usually  about  the  fourth  day  it  is  noticed  that  the  baby 
is  extremely  fretful  and  more  or  less  cyanotic;  the  symptoms  rapidly 
progress,  the  child  becoming  profoundly  prostrated,  with  rapid  pulse 
and  respiration.  Jaundice  of  a  severe  type  appears,  the  skin  becoming 
deep  yellow  or  bronze,  the  cyanosis  more  marked,  especially  on  the 
body  and  legs,  while  the  temperature  may  be  either  normal  or  slightly 
elevated.  The  infant  loses  strength  rapidly.  Diarrhea  or  vomiting 
may  develop,  urination  is  frequent,  and  the  urine  voided  very  dark, 
containing  blood  cells,  hemoglobin,  renal  epithelium,  granular  casts, 
and  a  small  amount  of  albumin.  Before  death  the  child  often  becomes 
comatose,  and  may  die  in  convulsions.  The  typical  urinary  findings 
will  confirm  the  diagnosis.  The  disease  is  fatal  in  the  severe  form, 
and,  as  it  is  undoubtedly  the  result  of  an  infection,  the  treatment  is 
the  same  as  that  recommended  for  septic  infection. 

Melena  Neonatorum. — The  name,  melena,  is  applied  to  those  cases 
in  which  bleeding  occurs  either  from  the  bowel,  the  stomach,  or  from 
both.  It  is,  of  course,  well  understood  that  hemorrhage  from  the 
stomach  or  bowel  may  occur  in  various  diseases,  and  may  be  a  symp- 
tom of  many  dift'erent  pathological  conditions;  but,  as  hemorrhage  is 
often  the  only  dangerous  symptom  that  presents  itself,  and  one  which, 
if  not  controlled,  may  cause  the  death  of  the  infant,  its  consideration 
is  important.  IMelena  is  not  the  name  of  a  definite  specific  disease, 
but,  as  the  term  is  generally  used,  it  describes  a  symptom-complex; 
therefore,  it  is  well,  perhaps,  to  retain  it.  The  more,  however,  one 
studies  the  conditions  associated  with  hemorrhage  of  the  newborn, 
the  more  thoroughly  one  is  convinced  that  it  is  due  to  sepsis.  The  study 
of  the  coagulation  of  the  blood  in  these  hemorrhagic  cases  assists 
somewhat  in  explaining  the  persistence,  at  least,  of  the  bleeding.  The 
elements  that  are  normally  present  in  the  blood  and  which  produce 
coagulation  may  not  be  present  in  normal  amounts  or  there  may  be  a 
normal  amount  of  some  of  these  elements  and  a  deficiency  in  others. 
Whipple  has  recently  demonstrated  the  interesting  fact  that  old  fibrin 
has  been  found  in  the  alveoli  of  the  lungs,  but  that  no  fibrin  of  fresh 
formation  exists,  which  proves  that  the  elements  necessary  for  coagula- 
tion were  present  at  birth  and  that  they  disappeared  in  the  first  few 
days  following  birth.  The  reason  why  transfusion  of  blood  and  sub- 
cutaneous injections  of  blood  are  beneficial  in  these  cases  is  quite  clear 
when  we  consider  that  transfused  blood  or  injected  serum  may  supply 
the  elements  needed  to  restore  coagulation. 

Melena  includes  only  those  cases  in  which  the  source  of  the  bleed- 
ing is  in  the  gastro-intestinal  tract.  Blood  from  the  nose,  lips,  or 
mouth  may  be  swallowed  by  the  infant  and  later  vomited.  A  bleeding 
fissure  in  the  mother's  nipple  may  result  in  the  infant's  swallowing 
blood  during  nursing,  and  this  may  subsequently  be  vomited  or  appear 
as  blood  in  the  stools;  this  condition  is  not  spoken  of  as  melena. 
9 


130  ■     DISEASES  OF   THE  NEWBORN 

Hemophilia  is  rarely  the  cause  of  hemorrhage  during  the  first  few  days 
of  life ;  as  proof  of  this  is  the  fact  that  the  c^ses  of  melena  that  recover 
show  no  tendency  to  subsequent  bleeding. 

In  the  newborn  gastro-intestinal  hemorrhages  may  occur  in  many 
conditions,  as  already  stated  in  the  consideration  of  sepsis,  the  hemor- 
rhagic diseases  of  the  newborn,  Buhl's  d,isease,  and  Winckel's  disease. 
But  all  of  these  affections  give  rise  to  other  decided  symptoms  besides 
the  hemorrhages;  therefore,  they  can  be  differentiated,  at  least  clinic- 
ally, from  melena. 

Etiology. — Sepsis  is  the  most  common  cause  of  hemorrhage  in  the 
newborn,  and,  while  the  hemorrhage  of  sepsis  is  not  usually  a  single 
hemorrhage  unconnected  with  other  symptoms,  still  this  undoubtedly 
does  occur,  and  sepsis  is  now  accepted  as  the  usual  cause  of  melena. 
Many  observers  regard  syphilis  as  a  cause,  since  in  this  disease 
the  intima  of  the  small  vessels  and  capillaries  becomes  thickened,  cell 
infiltration  and  subsequent  connective-tissue  formation  produce  a 
narrowing  of  the  lumen  and  cause  venous  stasis  and  hemorrhage.  In 
the  newborn,  syphilis  of  the  liver,  as  well  as  abdominal  growths  and 
congenital  heart  disease,  may  also  produce  hemorrhage  from  the 
stomach  or  bowel.  In  a  few  cases  a  gastric  or  duodenal  ulcer  has  been 
found  at  autopsy,  and  less  often  an  ulcer  in  the  esophagus.  A  thrombus 
of  the  umbilical  vein  or  of  the  ductus  arteriosus  Botalli  may  possibly 
explain  the  presence  of  the  ulcers;  this  results  in  emboli  of  the  pan- 
creatic, duodenal,  or  gastric  artery,  followed  by  necrosis  and  ulcer. 

Some  cases  of  melena  are  caused  by  abdominal  pressur'e  and  injury 
during  labor;  and,  as  gastro-intestinal  hemorrhage  may  be  associated 
with  cerebral  hemorrhage,  a  bulging  fontanelle,  slow  pulse,  and 
asphyxia,  associated  with  gastro-intestinal  hemorrhage,  would  indicate 
a  possible  connection  between  the  brain  and  the  melena.  If  melena 
is  noticed  within  two  or  three  hours  after  birth  it  suggests  a  birth 
injury,  and  it  is  probably  due  to  some  other  cause  than  sepsis,  especially 
if  there  are  no  other  evidences  of  sepsis  before  or  during  labor.  In 
many  cases  of  melena,  however,  the  child  is  at  birth  apparently 
normal  and  in  perfect  health.  In  melena  the  bleeding  usually  begins 
in  the  first  four  days  of  life,  often  on  the  first  or  second  day.  In  some 
cases  no  definite  pathological  condition  can  be  found;  in  others  a 
simple  congestion  without  vilceration  or  small  hemorrhagic  areas  with 
erosions  of  the  gastro-intestinal  mucous  membrane  are  seen  at  autopsy. 
Blood  cultures  or  a  Wassermann  may  assist  in  deciding  as  to  the 
septic  or  syphilitic  origin  of  the  melena. 

Prognosis. — This  depends  upon  the  cause  of  the  melena,  and  upon 
the  amount  of  blood  lost.  In  some  cases  the  hemorrhage  is  small,  the 
bleeding  does  not  recur,  and  the  child  is  not  seriously  ill.  In  others 
the  hemorrhage  is  more  profuse,  and  the  child  becomes  pallid,  pros- 
trated, and  is  in  shock.  In  the  most  severe  cases  the  infant  passes 
rapidly  into  collapse  and  dies.  The  mildest  symptoms  may  be  followed 
by  the  most  alarming  hemorrhage,  so  that  one  is  always  fearful  of  the 
outcome  until  the  child  has  entirelv  recovered. 


HEMORRHAGE   IN   THE  NEWBORN  131 

Treatment. — The  best  treatment  is  transfusion  of  blood  repeated 
in  twenty-four  hours  if  necessary;  next  to  transfusion  is  the  injection 
subcutaneously  of  human  blood  serum,  4  drams  (15  c.c),  which  may  be 
repeated  every  eight  or  twelve  hours  as  long  as  the  symptoms  persist. 
Horse  serum  may  be  used  if  it  can  be  procured  more  readily  than 
human  serum,  or  diphtheria  antitoxin,  containing,  as  it  does,  horse 
serum,  may  be  employed.  The  two  latter  may  be  used  in  doses  of  3 
drams  (11  c.c),  and  repeated  every  eight  or  twelve  hours  if  necessary. 
Sterile  gelatin  in  10  per  cent,  solution,  injected  subcutaneously  in 
4  dram  (15  c.c.)  doses  and  repeated  every  twelve  hours,  is  of  value  in 
this  disease  and  it  may  also  be  given  by  the  mouth  in  5  per  cent, 
solution  every  three  hours  in  as  large  amounts  as  the  child  can  take 
and  retain  without  producing  nausea  and  vomiting.  If  the  child  is 
extremely  weak,  with  cold  extremities,  whisky,  20  drops  every  two 
hours,  should  be  given,  and  external  heat  applied. 

Erysipelas. — Erysipelas  is  due  to  the  entrance  into  the  system  of 
septic  material.  The  infection  usually  takes  place  through  the  umbili- 
cus, although  it  may  enter  through  a  scratch  or  abrasion  in  any 
portion  of  the  body,  especially  in  the  genital  region,  scalp,  or  face. 
While  erysipelas  in  the  newborn  was  formerly  not  uncommon,  the 
modern  practice  of  aseptic  obstetrics  has  reduced  the  number  of  cases 
very  greatly.  ^ 

Etiology. — It  is  not  as  yet  dejBnitely  settled  what  the  specific  organism 
of  erysipelas  is.  Many  observers  believe  that  streptococci  positivelv 
produce  the  disease,  and  there  is  considerable  experimental  proof  to 
support  this  view.  The  infection  may  be  brought  to  the  child  by  the 
nurse,  the  physician,  unclean  dressings  or  soiled  clothing.  Erysipelas 
is  more  liable  to  develop  in  the  infant  if  the  mother  is  septic,  the 
infection  being  conveyed  to  the  child  by  the  infected  lochia  either 
through  infected  dressings,  clothing,  or  the  soiled  hands  of  an 
attendant. 

Symptoms. — The  infant  offers  only  a  slight  resistance  to  the  infection, 
consequently  the  disease  shows  a  tendency  to  spread  and  frequently 
extends  more  or  less  rapidly  over  a  wide  superficial  area.  In  early 
life  it  may  also  involve  not  only  the  skin  but  also  the  subcutaneous 
tissues.  It  usually  appears  first  from  the  sixth  to  the  tenth  day  after 
birth,  and,  if  at  the  umbilicus,  the  redness  and  swelling  quickly  involve 
the  neighboring  portions  of  the  abdomen  and  spread  to  the  pubic 
region  and  down  one  or,  perhaps,  both  thighs.  If  it  begins  at  the 
corner  of  the  eye  or  in  the  region  of  the  ear,  or  in  the  scalp,  it  quickly 
spreads  over  the  entire  face,  and  commonly  extends  also  to  the  neck 
and  upper  chest.  The  involved  area  is  red,  edematous  and  hot.  The 
systemic  symptoms  are  marked.  There  is  usually  high  fever,  102° 
to  105°  F.,  although  the  temperature  often  shows  wide  fluctuations, 
and  it  may  be  normal  or  subnormal.  Rapid  pulse,  marked  prostration, 
and  often  loss  of  appetite,  with  vomiting  and  diarrhea  and,  possibly, 
convulsions  are  common  symptoms.  Wasting  ma}'  be  rapid,  although 
if  the  child  takes  and  retains  the  breast,  and  there  is  no  diarrhea,  it 


132  DISEASES  OF   THE  NEWBORN 

may  not  be  especially  noticeable.  Hemorrhages  from  the  navel, 
intestine  or  beneath  the  skin  may  occur,  and  jaundice  may  be  a 
marked  symptom.  Bronchopneumonia  is,  in  erysipelas,  as  in  so  many 
of  the  dangerous  illnesses  of  infants,  a  not  unusual  complication. 
Septic  arteritis,  phlebitis,  and  peritonitis  are  quite  often  associated 
with  an  erysipelas  which  originates  at  the  umbilicus,  and  sloughing 
of  the  subcutaneous  tissues  is  much  more  common  in  infants  than  in 
older  children  or  adults.  Septic  infection  of  the  lungs,  cerebral  men- 
inges, and  pericardium  are  frequently  found  at  autopsy.  The  liver, 
kidneys,  and  spleen  are  less  often  involved. 

Prognosis. — Erysipelas  in  the  newborn,  especially  if  it  begins  at 
the  umbilicus,  is  a  dangerous  disease  and  often  ends  fatally,  and  if 
internal  organs  are  involved  the  prognosis  is  unfavorable.  The  less 
severe  cases  which  involve  the  scalp,  face,  and  chest  are  dangerous  but 
not  necessarily  fatal.  In  children  of  one  year  or  older  the  prognosis 
is  much  more  favorable,  although  even  in  the  older  children,  in  my 
experience,  the  disease  shows  a  much  greater  tendency  to  spread  than 
in  the  adult  and  is  apt  to  run  a  much  longer  course. 

Treatment. — As  erysipelas  in  the  newborn  is  the  result  of  septic 
infection  prophylactic  treatment  should  embrace  the  aseptic  care 
of  all  lesions  of  the  skin  or  mucous  membrane  occurring  at  birth. 
The  umbilicus  especially  should  be  treated  according  to  modern 
aseptic  methods.  Dry  dressings  are  the  only  ones  that  should  be  used. 
At  the  first  sign  of  infection,  strict  antiseptic  methods  are  necessary. 
Daily  washing  of  the  infected  part  with  1  to  1000  bichloride  solution 
and  the  application  of  gauze  kept  wet  with  this  solution  are  of  assistance 
in  limiting  the  spread  of  the  infection.  Prophylaxis  also  includes 
the  absolute  separation  of  the  child  from  a  septic  mother.  It  is  of  the 
first  importance  to  sustain  the  child's  strength  and  for  this  purpose 
breast  milk  is  by  far  the  most  useful  food.  Whisky,  10  drops  every 
two  hours,  may  be  given  to  combat  the  general  depression. 

Local  applications  to  the  affected  area  tend  to  relieve  somewhat  the 
intense  bm-ning  and  pain.  Ichthyol,  10  to  15  per  cent,  in  lanolin, 
is  one  of  the  best  local  applications.  It  partially  relieves  the  pain 
and  may  possibly  have  some  influence  upon  the  erysipelatous  inflam- 
mation. Gauze  dressing  kept  wet  with  normal  salt  solution  and  applied 
over  the  inflamed  portion  lessens  the  intense  burning  of  the  skin. 
Unguentum  Crede  rubbed  into  the  healthy  skin  daily  is  recommended 
by  many  careful  observers.  Antistreptococcic  serum,  4  drams  (15  c.c), 
administered  every  twenty-four  hours,  is  a  remedy  that  has  been  largely 
used  in  the  treatment  of  this  condition,  and,  while  the  results  are  not 
always  favorable,  still  there  is  no  question  but  that  it  is  well  worthy 
of  a  trial  in  severe  cases.  Vaccine  treatment  vies  with  antistrepto- 
coccic serum  as  the  best  method  to  employ.  Unfortunately  erysipelas 
of  the  newborn  is  usually  of  such  a  virulent  type  that  often  no  plan 
of  treatment  can  bring  about  a  cure,  but,  personally,  I  believe  that  all 
cases  should  have  the  benefit  of  either  the  vaccine  or  antistreptococcic 
serum,    One  must  not  expect  the  rapid  cures  that  have  so  often  been 


TETANUS  133 

rc])()rtc(l  as  follovviiij^  this  treatment  in  adnlts,  but  il'  used  daily  it  is 
of  assistance  in  the  erysipelas  of  the  newborn  although  of  much 
greater  benefit  in  erysipelas  of  older  children. 

TETANUS  (TRISMUS  NEONATORUM). 

This  is  an  acute  infectious  disease  due  to  the  entrance  into  the 
body,  through  a  wound,  of  the  tetanus  bacillus. 

Etiology. — The  infection  usually  occurs  through  the  umbilical 
wound,  although  it  may  enter  through  the  umbilical  vessels  or  any 
wound  or  abrasion  in  the  child's  body.  It  is  essentially  a  filth-born 
disease  and  is  usually  found  where  the  surroundings  of  the  child  are 
unclean.  It  may  be  carried  to  the  open  umbilical  wound  by  soiled 
hands  and  dressings,  or  by  the  dust-laden  air.  The  bacillus  is  usually 
found  in  the  top-soil  of  garden  earth,  but  not  at  a  greater  depth 
than  one  foot,  and  in  the  ex^crement  of  animals,  especially  that  of  the 
horse.  Tetanus  is  more  common  in  tropical  countries,  and  the  colored 
race  is  particularly  susceptible.  Since  the  cause  of  the  disease  has 
become  known  the  number  of  cases  has  greatly  diminished. 

The  bacilli  of  tetanus  increase  rapidly  in  numbers  at  the  point  of 
infection,  but  remain  for  a  short  period  of  time  only,  being  evidently 
short-lived.  A  few  only  of  the  bacilli  are  absorbed;  the  toxins  produced, 
however,  enter  the  lymph  channels  and  combine  with  the  motor 
cells,  in  the  anterior  cornua  of  the  cord  and  medulla,  increasing  greatly 
the  excitability  and  irritability  of  these  motor  cells,  so  that  the  slightest 
external  irritation  is  sufficient  to  produce  tetanic  spasms.  There  is  no 
involvement  of  the  muscles  of  the  peripheral  nerves,  as  is  shown  by  the 
fact  that  the  tetanic  Spasms  cease  if  the  nerve  trunks  are  divided. 
So  far  as  is  known  the  disease  produces  no  definite  lesions  in  the 
internal  organs  of  the  body. 

Symptoms. — The  first  symptoms  usually  appear  from  the  fifth  to  the 
twelfth  day  after  birth;  rarely  after  three  weeks.  The  sp.ecial  symp- 
toms are — continued  contraction  of  the  voluntary  muscles,  and  the 
development  at  irregular  intervals  of  tetanic  spasms  of  greater  or 
less  severity.  The  first  symptom  noticed  is  the  inability  of  the  child  to 
nurse;  this  is  due  to  the  fact  that  the  child  cannot  open  its  mouth 
— it  already  has  trismus  or  lockjaw.  The  spasm  spreads  to  the  face 
producing  a  characteristic  expression — the  so-called  risus  sardonicus. 
The  forehead  is  drawn  into  deep  wrinkles,  the  eyes  are  tightly  shut,  the 
mouth  is  closed  and  puckered.  The  muscles  of  the  neck  and  back  are 
the  next  involved.  The  head  is  drawn  backward,  the  abdominal 
muscles  become  fixed,  the  arms  are  flexed  at  the  elbows,  the  legs  are 
stiff  and  extended.  The  elbows  and  knees  can,  with  difficulty,  be 
either  flexed  or  extended,  and  opisthotonos  develops.  The  tonic 
spasms  increase  in  number  and  severity  and  the  slightest  reflex  is 
sufficient  to  produce  the  spasm.  The  merest  touch,  the  effort  of 
nursing,  or  a  current  of  air  may  bring  on  an  attack.  iVs  the  disease 
progresses  the  periods  of  relaxation  occur  less  often  and  are  of  shorter 


134  DISEASES  OF   THE  NEWBORN 

duration.  The  arms  remain  more  or  less  continuously  stiff  and  flexed, 
the  hands  tightly  closed,  the  legs  stiff",  the  jaws  closely  locked,  and  the 
child  swallows  \\ith  difficulty  or  not  at  all.  Owing  to  a  spasm  of  the 
laryngeal  muscle  the  respiration  may  be  noisy  and  dyspnea  and 
asphyxia  may  be  more  or  less  marked.  The  contraction  of  the  muscles 
and  the  spasm  may  relax  during  sleep.  The  pulse  is  accelerated, 
albumin  is  usually  present  in  the  urine,  and  there  may  be  other  signs 
of  septic  infection.  The  navel  may  appear  normal,  although  very 
commonly  it  presents  an  unhealthy  and  ulcerated  appearance,  accom- 
panied by  a  thick,  purulent  discharge.  In  the  severe  cases  the  tempera- 
ture is  usually  high,  104°  to  106°  F.  The  fatal  cases  usually  run  a  rapid 
course,  death  occurring  commonly  in  from  six  to  forty-eight  hours 
after  the  onset  of  the  symptoms.  Recovery  may  occur,  however,  even 
in  the  worst  cases.  In  the  milder  cases  the  temperature  is  lower, 
100°  to  102°  F.,  and  the  spasm  is  limited  to  the  jaws,  face,  and  neck. 
The  attacks  gradually  diminish  in  frequency  and  severity,  and  the  case 
may  go  on  to  recovery.  In  these  cases  the  spasm  relaxes  to  a  greater  or 
less  degree,  the  child  gradually  breathes  and  sw^allows  better,  and  the 
intervals  betw^een  the  spasms  increase  in  length.  In  those  infants  that 
recover  the  symptoms  last,  as  a  rule,  from  a  few  days  to  three  weeks. 
The  child  is^left  emaciated  by  the  disease,  and  following  the  spasm  is 
invariably  weak  and  exhausted. 

Diagnosis. — The  diagnosis  is  usually  made  without  any  great  diffi- 
culty. The  development  of  trismus  as  an  earl}'  sign,  and  the  continued 
contractions,  well  marked  in  the  severe  cases  and  present  in  a  less 
degree  in  the  mild  cases,  with  the  occurrence  of  tetanic  spasms  at 
irregular  intervals,  are  very  suggestive  of  the  disease.  Tonic  con- 
vulsions may  occur  with  meningitis,  and  congenital  spastic  paraplegia 
may  follow  cerebral  disease,  but  lockjaw  is  not  present  and  slight 
external  causes  do  not  provoke  a  tetanic  spasm. 

Prognosis. — This  depends  upon  the  severity  of  the  case,  the  time 
at  which  the  first  symptoms  develop,  and  the  duration  of  the  symptoms. 
The  more  severe  the  symptoms  and  the  earlier  they  appear  the  graver 
the  prognosis;  the  later  the  symptoms  develop  and  the  longer  they 
persist  the  better  the  prognosis.  Sporadic  tetanus  is  less  apt  to  be 
fatal  than  epidemic  tetanus.  Modern  treatment  is  helpful  in  reducing 
the  mortality;  although  probably  75  per  cent,  of  the  cases  end  fatally. 

Treatment. — As  the  majority  of  cases  occur  from  umbilical  infection 
the  aseptic  care  of  the  cord  is  of  the  utmost  importance.  This  includes 
the  aseptic  care  of  the  umbilicus  until  the  wound  at  the  navel  has 
entirely  healed.  In  those  regions  w^here  epidemics  of  tetanus  have 
occured  the  antiseptic  treatment  of  the  cord  and  its  subsequent  care 
are  essential  as  a  means  of  proph}^laxis.  As  soon  as  the  first  suspicious 
symptoms  of  tetanus  appear,  tetanus  antitoxin  should  be  administered. 
In  order  to  be  of  much  benefit  the  antitoxin  should  be  used  early,  as 
the  toxins  of  tetanus  combine  with  the  motor  cells  in  the  cord  and 
medulla,  and  after  combination  are  only  slightly  influenced  by  the 
antitoxin  administered.    The  toxins  still  circulating  in  the  blood  can, 


SCLEREMA  '  135 

however,  be  neutralized.  The  antitoxin  apparently  does  no  liarm 
even  if  administered  in  large  doses,  and  consequently  should  be  used 
freely.  It  may  be  administered  by  lumbar  puncture,  intravenously 
or  subcutaneously.  Ten  cubic  centimeters  of  spinal  fluid  should  be 
withdrawn  by  lumbar  punctm-e,  and  10  c.c.  of  tetanus  antitoxin 
injected  every  twelve  or"  twenty-four  hours  as  long  as  the  severe 
symptoms  persist;  if  the  symptoms  become  less  marked  the  injections 
may  be  given  every  second  or  third  day.  If  not  injected  into  the 
spinal  canal  the  antitoxin  may  be  given  either  intravenously  or  sub- 
cutaneously in  the  same  doses  as  recommended  by  lumbar  puncture. 
Bromide  of  soda  in  5-grain  doses  combined  with  chloral,  1  grain, 
may  also  be  given  every  hour  either  by  the  mouth  or  rectum  as  long  as 
the  violent  symptoms  persist.  Small  doses  are  useless  and  large  ones 
essential  in  assisting  to  control  the  symptoms.  If,  owing  to  the  trismus, 
the  child  is  unable  to  swallow  it  may  be  fed  breast  milk  with  a  tube 
passed  through  the  nose.  Absolute  rest  and  quiet  should  be  insisted 
upon,  and,  as  the  tetanic  spasms  are  often  produced  by  very  slight 
causes,  all  external  sources  of  irritation  should  be  removed.  While 
the  treatment  of  tetanus  with  antitoxin  has  not  given  good  results, 
still,  in  such  a  dangerous  disease,  it  is  well  worthy  of  trial,  and,  if 
possible,  should  be  administered  in  every  case. 

SCLEREMA. 

In  this  disease  the  skin  and  subcutaneous  tissues  become  firm  and 
hard.  The  induration  of  the  tissues  usually  appears  first  in  the  legs 
below  the  knees  and  gradually  extends  upward,  involving  a  portion  or 
practically  all  of  the  body.  The  genitals,  soles  of  the  feet,  and  palms 
of  the  hands  are  not  involved. 

Etiology. — The  etiology  is  still  in  doubt.  The  composition  of  the 
fat  of  the  newborn,  containing  as  it  does  about  20  per  cent,  less  of 
oleic  acid  as  compared  with  the  adult,  and  a  greater  amount  of  stearic 
and  palmitic  acids,  is  believed  by  some  to  predispose  the  infant  to 
the  disease.  Others  believe  that  it  is  an  infectious  disease,  and,  while 
its  infectious  origin  has  not  been  proven,  personally  I  believe  that  it 
will  be  sh5wn  to  belong  to  this  class.  Streptococci  have  been  found  at 
autopsy.  Still  others  believe  it  is  associated  with  certain  changes  in 
the  nervous  system.  Prematurity  and  unliygienic  surroundings  are 
predisposing  causes,  and  it  is  more  common  in  institutions  than  in 
private  practice.  In  atrophic  infants  a  few  months  old,  sclerema  may 
follow  cholera  infantum  or  an  enteritis  with  frequent  watery  stools. 

Pathological  Anatomy. — The  skin  and  subcutaneous  tissues  are  dry 
and  hard.  The  superficial  fat  is  firm  and  dry.  Atelectasis  is  often 
present,  and  enteritis  is  not  uncommon  in  children  who  have  lived  for 
some  days.    Hemorrhages  into  the  lung  and  myocardium  may  occur. 

Symptoms. — It  is  an  uncommon  disease,  and  may  occm-  in  the  first 
few  days  of  life,  or,  in  weak  and  premature  infants,  as  late  as  the 
third  or  fourth  month.    The  most  common  locations  are  the  calves  of 


136  DISEASES  OF   THE  NEWBORN 

the  legs^  mons  veneris,  cheeks,  thighs,  and  lower  portion  of  the  trunk, 
more  particularly  those  parts  of  the  body  where  fat  is  abundant. 
As  a  rule  the  disease  lasts  in  the  severe  cases  only  a  few  days.  The 
temperatiu-e  falls  soon  after  birth  and  never  returns  to  normal.  A 
temperatm-e  of  95°  F.  is  quite  common;  it  may  fall  as  low  as  85°  F., 
and  cases  have  been  reported  where  it  has  fallen  as  low  as  72°  F.  The 
baby  feels  cold,  and  its  skin  is  hard  and  atrophied.  The  child  loses  in 
weight,  its  legs  become  stiff,  and  it  lies  absolutely  quiet  in  bed. 
The  mucous  membranes  are  dry,  the  sleep  is  restless,  the  urine  is 
scanty,  and  there  is  constipation.  The  amount  of  nourishment  taken 
is  small,  the  respirations  are  superficial  and  slow%  often  below  18. 
The  pulse  is  slow,  falling  to  60  or  even  lower  in  some  cases,  and  is 
difficult  to  find.  The  lips  and  finger  tips  may  be  cyanotic,  and  there 
may  be  more  or  less  associated  edema.  The  skin  may  be  of  a  blue  or 
reddish  tint,  and  a  serous  fluid  exudes  if  the  skin  is  slightly  incised 
or  punctured.  The  child  utters  a  sharp  cry;  this  is  more  often  noticed 
in  older  children.  Jaundice  may  be  present,  albumin  in  the  urine  is 
not  uncommon,  and,  less  often,  granular  casts  and  red  blood  cells  are 
found,  and  occasionally,  sugar.  The  younger  the  child  the  more  serious 
the  prognosis  and  the  more  rapid  the  course  of  the  disease.  In  the 
fatal  cases  the  asthenia  becomes  progressively  greater,  and  the  infant 
sinks  into  coma  and  dies.  In  the  cases  that  recover  the  hardness  of 
the  skin  and  subcutaneous  tissues  gradually  lessens,  the  normal  color 
returns,  and  the  infant  slowly  gains  in  vitality  and  strength.  Effusions 
have  been  found  in  the  pleura  and  peritoneum,  and  pneumonia  may 
develop  as  a  complication. 

Diagnosis. — Hardness  of  the  skin,  subnormal  temperature,  and  stiff- 
ness of  the  body  are  characteristic. 

Prognosis. — The  prognosis  is  bad  in  the  newborn;  probably  about 
35  per  cent.  die.  The  more  vigorous  the  child  the  better  is  the  prospect 
of  recovery. 

Treatment. — The  best  results  are  obtained  by  combating  the  low 
bodily  temperature.  This  is  best  accomplished  by  placing  the  child 
in  an  incubator,  or  by  keeping  it  surrounded  with  hot  water  bags,  or 
the  heat  may  be  supplied  by  an  electric  warmer.  Hypodermoclysis 
of  normal  salt  solution,  or  the  introduction  of  salt  solution  per  rectum 
according  to  the  ]Murphy  method,  is  a  treatment  that  has  apparently 
been  beneficial  in  some  cases.  The  child  should  be  nourished  by 
breast  milk.  If  too  weak  to  nurse  the  breast  milk  may  be  fed  to  the 
infant  in  small  quantities  at  regular  intervals. 

SCLERO-EDEMA. 

This  is  not  a  rare  disease.  It  is  most  common  in  small,  weak,  and 
premature  infants  or  in  twins.  A  history  of  syphilis  may  exist.  It 
has  been  found  associated  with  congenital  heart  disease  and  with 
nephritis.  It  is  most  likely  to  appear  in  winter  and  in  cold  climates, 
in  institutions  and  hospitals,  and  where  the  surroundings  and  hygienic 


SCLERO-EDEMA  137 

conditions  are  unfavorable.  It  usually  develops  between  the  second 
and  fifth  days  of  life,  rarely  after  the  fifteenth  day. 

Etiology. — Poor  circulation  and  feeble  respiration  are  factors  present 
in  practically  all  cases.  If  an  infant  so  aft'ected  is  exposed  to  cold  it 
increases  the  liability  to  develop  this  condition.  It  is  claimed  by  some 
that  sclero-edema  is  the  result  of  an  infection. 

Pathological  Anatomy. — iVn  exudate  is  present  in  the  skin  and 
underlying  fatty  and  muscular  tissues.  Venous  congestion  is  found  in 
the  organs  of  the  abdomen  particularly,  congestion  of  the  pul- 
monary tissues  with  minute  hemorrhages  is  common,  and  the  myo- 
cardium may  show  fatty  changes.  The  microscopic  examination 
of  the  skin  shows  no  specific  lesion;  only  a  swelling  and  dilatation  of 
the  lymphatics  and  minute  vessels  can  be  demonstrated. 

Symptoms. — It  is  noticed  almost  immediately  after  birth  that  the 
infant  is  restless  and  nurses  poorly.  The  edema  usually  appears 
first  on  the  dorsum  of  the  foot,  and  in  many  cases  is  soon  afterward 
seen  in  the  cheeks  and  inferior  portion  of  the  abdomen.  The  affected 
tissues  are  swollen  and  hard  and  pit  on  pressure.  The  skin  and  sub- 
cutaneous tissues  are  much  more  tense  than  is  usually  found  in  edema, 
and  the  muscles  are  also  more  or  less  involved,  although  to  a  less 
degree.  The  affected  part  may  be  a  reddish  pink,  blue,  or  mottled 
color,  and  the  superficial  tissues  may  be  lifted  up  from  the  underlying 
structures.  The  skin  feels  cold,  and  if  the  swelling  is  extreme  the 
child's  body  is  stiff  and  almost  motionless.  The  infant,  owing  to 
edema,  does  not  lose  weight.  The  temperature  is  subnormal  in  all 
cases.  In  mild  cases  it  may  average  95°  F.,  and  in  severe  ones  it  may 
fall  to  90°  F.,  or  even  85°  F.  The  pulse  is  weak  and  the  respiration 
unnaturally  slow.  The  urine  is  diminished  in  amount  but  albumin 
is  not  usually  present.  Swelling  of  the  scrotum  and  penis  generally 
occurs  and  a  large  part  of  the  body  may  be  involved.  In  the  worst 
cases  the  child  gradually  becomes  weaker  and  passes  into  a  stupor 
which  ends  in  death  in  from  three  to  six  days.  In  the  milder  cases  the 
temperature  gradually  returns  to  normal,  the  child's  respiration  and 
circulation  improve,  the  edema  slowly  disappears,  and  the  patient 
recovers,  the  duration  of  the  disease  being  eight  to  fourteen  days. 
Pneumonia  may  appear  as  a  complication. 

Diagnosis. — In  well-marked  cases  the  diagnosis  is  not  difficult. 
In  sclerema  the  aftected  parts  do  not  pit  on  pressure,  they  are  much 
firmer  than  in  sclero-edema,  and  the  scrotum  and  penis  are  not 
involved.  In  the  edema  of  nephritis  the  tissues  are  much  softer  and 
more  pliable. 

Prognosis. — In  the  mild  cases  the  prognosis  is  favorable  but  is  bad 
in  severe  cases,  especially  if  heart  disease,  pneumonia,  or  nephritis 
coexist. 

Treatment. — Prophylaxis  includes  the  prevention  of  unnecessary 
chilling  of  the  body  in  weak  and  premature  infants,  the  application  of 
external  heat  in  all  such  cases,  and  insistence  upon  breast-feeding. 
The  most  important  part  of  the  treatment  is  the  application  of  external 


138  DISEASES  OF   THE  NEWBORN 

lieat.  This  is  best  accomplished  by  placin^i;  the  child  in  an  incubator, 
or  it  may  be  surrounded  Avith  hot  water  bags,  and  its  entire  body 
\\Tapped  in  cotton  kept  in  place  with  woolen  bandages.  Hot  baths 
are  also  of  assistance  and  a  thorough  massaging  of  the  child  with  10 
per  cent,  of  iodide  of  ammonium  in  glycerine  has  been  recommended  as 
having  served  a  useful  purpose.  Oxygen  inhalations  are  of  benefit, 
and  breast  feeding  is  absolutely  essential.  If  unable  to  nurse,  the 
infant  must  be  fed  with  a  spoon,  medicine  dropper,  or  by  gavage. 

ACHONDROPLASIA    (CHONDRODYSTROPHY— MICROLELIA) . 

In  this  disease  the  arms  and  legs  at  birth  are  short  in  proportion 
to  the  trunk,  which  is  of  about  the  normal  size.  If  the  children  affected 
survive  the  first  few  years  of  life,  they  often  live  on  to  advanced  age, 
and  become  robust  and  muscular,  but  are  dwarfs. 

Etiology. — The  disease  aifects  both  sexes  equally,  but  is  usually 
transmitted  by  males,  and  has  been  known  to  exist  in  three  successive 
generations  of  males.  The  children  of  parents  who  have  achondroplasia 
may  inherit  the  disease  or  may  be  absolutely  normal..  The  changes 
in  the  affected  bones  probably  occur  in  the  first  few  months  of  fetal  life. 
There  are  no  known  predisposing  influences,  the  true  cause  being 
entirely  a  matter  of  conjecture  and  theory. 

It  has  been  suggested  that  a  perversion  of  the  internal  secretion 
which  affects  the  development  of  the  epiphyseal  cartilages  may  be  the 
cause;  that  the  changes  may,  possibly,  be  toxic  in  nature;  may  be 
due  to  an  infection;  or  may  be  associated  with  certain  changes  in  the 
placenta.  Summers  and  Wallace  have  recently  described  a  cretinistic 
variety  of  achondroplasia  in  which  certain  changes  were  found  in  the 
thyroid  gland;  but  in  these  cases  there  were  cretinistic  symptoms  that 
are  not  present  in  typical  cases  of  achondroplasia. 

Pathological  Anatomy. — In  this  disease  the  bony  system  of  the  infant 
at  birth  shows  deformities  which  are  the  result  of  interference  with  the 
normal  deposit  of  bone  cells  in  the  fetal  cartilage.  No  changes,  or  but 
slight  ones,  are  found  in  those  bones  in  which  ossification  develops 
intramembranously — as  in  the  fiat  bones  of  the  skull — nor  in  those 
which  have  a  tendency  to  remain  cartilaginous  in  utero;  but  changes 
are  especially  noticeable  in  those  bones  in  which  ossification  of  the 
cartilage  normally  takes  place  in  fetal  life. 

The  bones  of  the  arms  and  legs  are  the  ones  most  markedly  deformed. 
The  tribasilar  bone  in  the  floor  of  the  skull  often  partly  ossifies  during 
fetal  life,  and  prevents  normal  development  of  the  base  of  the  skull, 
consequently  the  cranium  is  expanded  above  and  an  unusual  promi- 
nence of  the  parietal  and  frontal  bones  results.  The  faulty  nutrition 
of  bone  cells  is  especially  marked  in  the  long  bones — bowing  and 
shortening  them — and  is  the  result  of  interference  with  endochondral 
ossification  which  is  most  marked  at  the  extremities  of  the  long  bones. 

The  pathological  changes  are  found  only  in  endochondral  ossifica- 
tion.   Bone  formation  from  the  periosteum  continues,  and  the  shafts 


ACHONDROPLASIA 


139 


of  tlie  long  |>()nes  ai'e  formed  largely  from  this  periosteal  growth.  The 
epiphyses  are  more  or  less  enlarged.  The  long  bones  fail  to  increase  hi 
length  owing  to  dystrophy  of  the  epipliyseal  cartilages  during  intra- 
uterine life;  in  some  cases  a  fibrous  ingrowth  of  the  periosteum  between 
the  epiphysis  and  the  diaphysis  is  present  and  tends  to  check  the 
increase  in  length. 

The  thyroid  gland  and  all  other  organs  are  apparently  normal. 
The  chest  is  smaller  than  normal,  and  the  ribs  are  badly  formed.  The 
bones  of  the  limbs,  the  ossa  innominata,  the  ribs,  and  the  basa  occipital 
are  especially  affected. 


Fig.  20. — Achondroplasia  in  a  child  aged  two  years. 

Symptoms. — The  infant  may  be  stillborn  or  die  in  the  first  few 
weeks  of  life.  The  short  arms  and  legs,  with  the  trunk  much  longer  in 
proportion  than  the  extremities,  produce  an  unusual  t\'pe  of  dwarf, 
the  ordinary  height  being  from  40  to  48  inches.  The  upper  arms  and 
the  thighs  are  proportionately  shorter  than  the  forearms  and  legs.  The 
head  is  large,  with  prominent  forehead  and  saddle-shaped  nose,  which 
constitute  a  characteristic  type  of  face.  The  features  are  large  and 
massive. 

The  maximum  circumference  of  the  head  is  above  the  normal, 
and  may  suggest  hydrocephalus,  although  hydrocephalus  and  chondro- 
dystrophy have  nothing  in  common.  The  normal  spinal  curve  in  the 
lumbar  region  is  much  exaggerated,  the  scapulse  are  short.  The 
abdomen  is  large  and  prominent,  the  buttocks  unnaturally  thick  and 
heavy,  the  genital  organs  are  normal. 


140  DISEASES  OF   THE  NEWBORN 

During  early  child  life  the  muscular  development  is  usually  poor, 
and  the  child  is  late  in  walking.  The  anterior  fontanelle  often  remains 
open  until  the  end  of  the  second  or  third  year,  or  even  later.  As  the 
child  grows  older,  the  muscles  of  the  arms,  legs,  and  body  often  become 
unusually  well  developed,  and  the  resemblance  to  cretinism  is  more  or 
less  marked.  The  condition  is,  however,  not  of  the  same  nature  as 
cretinism,  and  is  entirely  uninfluenced  by  thyroid  treatment.  The 
hands  are  thick,  the  fingers  short  and  nearly  of  equal  length,  and  the 
fingers  are  spread  apart  by  an  usual  development  at  the  second  joint, 
which  produces  the  so-called  "trident  hand." 

Mentally  the  children  affected  are  usually  rather  subnormal,  but 
their  mental  powers  are  not  markedly  defective,  and  they  may  even 
be  normal.  As  a  rule,  however,  they  develop  slowly,  are  late  in  talking, 
and  behind  the  normal  child  in  acquiring  knowledge.  The  deformity 
in  the  sacral  region  and  pelvis  caused  by  defective  ossification  of  the 
innominate  bones  may  make  normal  labor  difficult  and  necessitate  the 
use  of  forceps,  or,  possibly,  the  performance  of  Cesarean  section. 

Diagnosis. — The  condition  has  been  confounded  with  hydrocephalus, 
rickets,  and  cretinism;  but  careful  examination  will  invariably  result 
in  a  correct  diagnosis.  X-ray  plates  will  show  the  short  and  curved 
bones  of  the  arms  and  legs,  and  will  aid  in  the  recognition  of  the  disease. 

Prognosis. — The  general  nutrition  of  the  infant  is  affected,  as  is 
evident  from  the  poor  ligamentous  and  muscular  development.  Many 
of  the,  children  die  during  birth,  or,  owing  to  poor  development,  soon 
afterward;  others,  as  has  been  stated,  may  live  to  extreme  old  age. 
They  marry  and  have  children,  and  their  offspring  may  either  show 
achondroplasia  or  be  absolutely  normal. 


PLATE  I 


Achondroplasia. 

^r^slTf?^r.f'^'^'^''^^^l    ^f""^    ^""^    epiphyses    with    ^.ery   short    shafts.       The 
TZs  Ina  the  th  "h"""  °"'"''   '"    proportion    than    the    trunk.       The  upper 

feg^  below  ;het?eel'''  proportionately  shorter   than    the   forearn^s    an/lhe 


CHAPTER  VIII. 
INFANT  FEEDING. 

Cow's  Milk. — The  infant  may  be  fed  on  cow's,  goat's  or  ass's  milk, 
but  as  the  milk  of  the  cow  is  almost  always  obtainable,  and  that  of 
the  ass  and  goat  is  often  difficult  to  procure,  cow's  milk  is,  for  practical 
purposes,  the  one  which  is  universally  adopted  in  the  United  States. 

Our  first  thoughts  in  regard  to  cow's  milk  should  be  of  the  cows 
and  the  farm.  The  herd  should  be  healthy  and  free  from  any  taint 
of  tuberculosis.  They  should  be  properly  fed  both  in  and  outside  of 
the  barn,  and  care  should  be  taken  to  see  that  the  pasture  fields  do  not 
contain  weeds  and  rank  growths.  The  cows  should  be  carefully 
groomed,  given  an  abundance  of  fresh  air  and  fresh  water,  and  the 
manure  should  be  removed  from  the  barn  as  frequently  as  possible. 

The  milkers  should  be  clean,  and,  if  milking  is  done  by  hand,  the 
milkers  should  wash  their  hands  just  before  milking,  and  the  milk 
be  received  into  the  pail  in  such  a  manner  as  to  avoid  any  contamina- 
tion from  the  cow's  udder  The  first  few  streams  of  milk  which  flow 
from  each  teat  should  be  thrown  away,  as  this  contains  the  major 
portion  of  the  bacteria. 

The  milk  should  be  cooled  to  45°  F.  within  an  hour  after  milking, 
and  kept  at  or  below  this  temperature  until  it  reaches  the  consumer. 

Much  could  be  written  about  the  production  and  care  of  milk, 
but  space  does  not  permit.  It  is,  however,  the  plain  duty  of  every 
physician  to  familiarize  himself  with  the  production  of  milk  as  seen  in  a 
model,  modern  dair-s-,  and  to  urge  upon  all  those  with  whom  he  comes 
in  contact  professionally  the  importance  of  a  good  and  unvarying 
milk  supply.  All  milk  used  in  infant  feeding  should  be  fresh  and  clean, 
should  contain  no  pathogenic  organisms  or  preservatives,  and  its 
chemical  composition  should  vary  from  day  to  day  as  little  as  possible. 
Unless  the  percentages  of  fat,  protein,  and  sugar  remain  fairly  constant, 
it  will  be  impossible  to  give  to  the  infant,  whose  bottles  are  prepared 
from  this  milk,  the  same  milk  mixture  each  day. 

If  the  herd  is  properly  cared  for  on  a  modern  farm,  there  is  less 
variation  in  the  mixed  milk  of  the  herd  than  is  noted  in  the  milk  of  a 
single  cow.  For  this  reason  it  is  wiser  to  use  mixed  milk  from  a  herd 
of  cows  rather  than  the  milk  of  a  single  cow.  The  milk  from  one  cow 
is  often,  however,  used  with  the  very  best  results  in  feeding  one  or 
more  infants,  but  one  should  be  certain  that  the  cow  receives  every 
requisite  care  and  attention. 

The  chemical  composition  of  the  milk  will  vary  according  to  the 
breed.  Holstein  cows  produce  a  large  amount  of  milk  with  an  average 
composition  of  fat  3  per  cent.,  sugar  4  per  cent.,  proteins  2.8  per  cent. 


142  INFANT  FEEDING 

Jersey  cows  usually  give  less  milk,  but  the  fat  will  often  average  5 
per  cent.,  sugar  from  4.5  per  cent,  to  5  per  cent.,  proteins  3.65  per  cent. 

The  milk  from  a  herd  of  healthy,  but  common,  varieties  of  cows  is 
to  be  preferred  to  that  of  high  bred  or  fancy  stock,  simply  because 
the  high  bred  animal  is  often  delicate  and  susceptible,  therefore  more 
sensitive  to  its  surroundings,  and  more  apt  to  become  temporarily 
sick  or  diseased  than  are  the  hardier  herds. 

The  average  composition  of  the  milk  of  such  a  herd  is  as  follows: 

Fat 3.5  to      4.0  per  cent. 

Sugar     .      . 4.0  to      4.5         " 

Proteins 3.5  to      4.0 

Ash 0.7  to      0.8 

Water    .      .      .' 88.3  to  86.7 


100      to  100 


The  importance  of  securing  a  clean,  raw  milk,  of  definite  chemical 
composition,  free  from  pathogenic  organisms,  containing  not  more 
than  10,000  bacteria  per  cubic  centimeter,  and  no  preservatives,  is 
readily  understood  and  appreciated. 

It  is,  of  course,  apparent  that  to  produce  such  milk  entails  much 
additional  expense  to  the  dairy  owner,  and,  of  course,  an  extra  high 
price  to  the  consumer.  Dairies  capable  of  producing  such  a  product, 
which  is  commonly  called  "certified  milk,"  are  now  established  near 
almost  every  large  centre  of  population,  and,  in  fact,  in  many  small 
communities  the  additional  price  which  certified  milk  brings  to  the 
producer  has  been  a  sufficient  stimulus  to  make  an  energetic  dairyman 
develop  a  model  farm. 

In  some  large  cities,  as  Philadelphia,  a  number  of  such  model  dairy 
farms  have  been  established,  and  the  resulting  competition  keeps  the 
standard  high,  and  the  public  is,  consequently,  all  the  better  protected. 
In  order  to  maintain  the  standard  of  certified  milk,  it  is  customary  to 
have  samples  bought  in  the  open  market,  and  examined  by  competent 
chemists  and  bacteriologists  who  are  selected  by  a  local  Milk  Com- 
mission to  whom  they  make  their  report. 

Bacteria  in  Milk. — Milk  is  one  of  the  best  culture  media  for  bacteria, 
although  their  growth  depends  largely  on  the  temperature.  Milk 
kept  at  45°  F.  will  show  very  little  bacterial  growth;  at  ordinary 
summer  heat,  70°  to  90°  F.,  the  growth  is  rapid.  All  milk  contains  a 
certain  number  of  bacteria,  and  a  low  bacterial  count,  such  as  10,000 
per  cubic  centimeter,  is  the  usual  standard  for  certified  milk. 

There  are,  as  a  rule,  fewer  bacteria  in  milk  bottled  at  the  farm  than 
in  milk  transported  in  large  cans  from  the  dairies,  and  sold  to  the 
consumer  from  the  cans.  A  milk  that  does  not  contain  more  than 
50,000  bacteria  in  winter  and  100,000  in  summer  per  cubic  centimeter 
is  generally  considered  good  milk. 

Cream  usually  contains  a  much  higher  bacterial  count  than  milk. 
In  gravity  cream,  especially,  the  bacterial  count  is  high,  as,  apparently, 
most  of  the  bacteria  are  carried  by  the  fat  globules  to  the  upper  cream 


COW'S  MILK  143 

layers.  Centrifugal  cream  contains  less  dirt  and  bacteria  than  gravity 
cream.  The  number  of  bacteria  within  certain  limits  is,  however, 
not  a  matter  of  vital  importance,  provided  that  no  pathogenic  bacteria 
are  present. 

If,  however,  the  bacterial  count  is  only  10,000  or  20,000  per  cubic 
centimeter  it  points  to  the  fact  that  the  conditions  under  which  the 
milk  is  produced  are  exceptionally  good;  consequently  it  indicates 
less  probability  of  pathogenic  organisms  being  present.  The  cleanliness 
of  the  cows,  the  barn,  and  the  milker,  the  fact  that  no  dry  fodder  is 
fed  to  the  cows  before  milking,  and  no  sweeping  permitted — both  of 
which  produce  dust — arid  the  careful  wiping  with  a  wet  cloth  of  the 
cow's  body,  especially  its  udder,  just  before  milking,  are  important 
aids  in  the  reduction  of  the  bacterial  count. 

The  sterilization  of  all  milk  containers,  the  straining  of  the  milk 
through  sterilized  cloths,  and  its  rapid  cooling,  with  absolute  cleanliness 
of  the  milkers,  are  also  factors  which  assist  in  reducing  the  bacterial 
count.  The  custom  of  bottling  milk  at  the  dairy  is  an  excellent  one, 
and  that  of  serving  all  milk  to  the  houses  of  consumers  in  bottles 
most  important. 

If  the  cow's  udder  is  diseased,  pyogenic  organisms  may  be  found  in 
the  milk,  or  the  germs  of  tuberculosis,  anthrax,  or  foot  or  mouth  disease 
may  enter  the  milk  directly  from  the  cow.  The  menace  to  public 
health  when  cows  are  infected  by  these  diseases,  and  the  danger  of 
transmitting  them  by  means  of  their  milk,  as  well  as  the  danger  of 
infecting  other  cows,  are  now  quite  generally  appreciated,  and  State 
laws  are  being  made  more  and  more  stringent. 

Of  the  pathogenic  bacteria  found  in  milk  the  most  important  is  the 
typhoid  bacillus,  which,  being  water-borne,  may  gain  access  to  the 
milk  in  many  ways,  especially  through  an  infected  milker,  or  by  using 
infected  water  for  cleaning  cans  and  diluting  the  milk.  Diphtheria 
and  scarlet  fever  may  be  spread  by  milk,  commonly  thi'ough  some  one 
who  has  the  disease,  and  is  employed  in  the  dairy. 

The  putrefactive  bacteria  in  milk  act  on  the  proteins  and  may  form 
toxins  which,  being  taken  by  the  infant  with  its  milk,  may  cause 
dangerous  symptoms;  or,  again,  certain  putrefactive  bacteria  may 
develop  rapidly  in  the  intestinal  tract  of  the  infant,  especially  if  the 
child  has  intestinal  indigestion,  and  often  produce  severe  or  even 
dangerous  symptoms. 

The  Souring  of  Milk. — This  is  caused  by  the  lactic  acid-producing 
group,  and  the  rapidity  of  their  growth  is  increased  by  the  milk  sugar. 
At  the  stage  of  souring  they  form  90  per  cent,  of  all  bacteria  present. 

The  Preservation  of  Milk. — Milk,  when  it  reaches  the  consumer,  is 
usually  a  mixed  product,  a  part  of  it  twelve  hours  old,  the  other  part 
twenty-four  hours  old.  This  milk  is  usually  the  day's  supply  for  the 
household,  so  that,  by  the  time  it  is  used,  some  of  it  is  forty-eight  hours 
old.  If  the  milk  comes  from  a  first-class  dairy,  where  absolute  cleanli- 
ness is  insisted  upon,  and  the  milk  is,  immediately  after  milking, 
removed  from  the  milking  barn,  and  rapidly  cooled  to  4,5°  or  T^O"  F., 


144 


INFANT  FEEDING 


and  kept  at  this  temperature  until  it  reaches  the  consumer,  it  ought 
to  be  fresh  and  sweet.  When  consumed  this  milk  should  not  have  a 
bacterial  count  above  that  which  is  considered  safe. 

Now,  as  a  matter  of  practical  every-day  experience,  we  know  that  the 
major  portion  of  the  milk  sold  is  not  produced  in  these  model  dairies, 
and  it  is  difficult  to  enforce  strictly  those  regulations  that  require 
the  milk  to  be  kept  cool  until  it  reaches  the  consumer,  although  much 
has  been  done  by  law  to  insure  the  keeping  of  milk  at  a  low  tempera- 
ture during  transportation. 

The  problem  is,  how  is  this  ordinary  market  milk  to  be  preserved? 
It  can  be  said  without  hesitation  that  it  is  most  unwise  to  add  to  the 
milk  any  chemical  preservative  whatsoever.  The  use  of  formaldehyde, 
salicylic  acid,  or  any  other  preparation  for  this  purpose  should  be 
forbidden  by  law.    Given  a  milk  which  we  believe  to  be  unfit  to  feed 

to  an  infant  or  child,  we  can  by  the 
application  of  heat  largely  destroy  the 
bacteria  present,  and  by  keeping  it  as 
cool  as  possible  after  this  heating  tend 
to  prevent  the  subsequent  growth  of 
bacteria  and,  also,  its  becoming  sour. 
In  other  words,  we  may  sterilize  or 
pasteurize  such  milk. 

Sterilization.  —  By  sterilization  we 
mean  the  heating  of  milk  to  the  boil- 
ing point,  212°  F.  or  100°  C.  This  is 
most  easily  accomplished  by  the  use 
of  an  Arnold  steam  sterilizer.  The 
milk  should  be  kept  at  212°  F.  for 
twenty  to  thirty  minutes,  and  then 
rapidly  cooled  by  placing  the  bottles  in 
the  rack  under  cool  running  water,  and 
then  setting  them  on  ice.  The  rapid 
cooling  is  important,  as  it  prevents 
the  separation  of  the  fat  globules. 
Among  the  very  poor  and  ignorant,  it  is  impossible  to  have  the  milk 
kept  on  ice  after  it  has  been  sterilized  for  the  usual  twenty  or  thirty 
minutes.  In  such  cases  it  is  easier  to  sterilize  the  milk  for  one  hour, 
as  such  milk,  if  kept  in  well  stoppered  bottles,  will  not  turn  sour,  and 
will  show  no  increase  in  the  growth  of  bacteria  for  twenty-four  hours 
or  longer.  If  an  Arnold  sterilizer  is  not  available,  the  bottles  of  milk 
may  be  placed  upright  in  a  vessel  containing  warm  water,  and  this 
water  may  be  boiled  for  twenty  to  thirty  minutes. 

Among  the  poorer  classes  the  day's  supply  of  milk  may  be  placed  in 
a  large  corked  jar,  the  jar  placed  in  water,  and  the  water  boiled  for  the 
requisite  number  of  minutes.  Sterilization  in  this  manner  will  destroy 
all  pathogenic  bacteria,  and  practically  all  of  the  other  bacteria,  but  it 
will  not  destroy  the  spores,  and  these  spores  may  subseqtiently  develop 
into  bacteria. 


Fig.  21. — Arnold  steam  sterilizer. 
(Abbott.) 


COW'S  MILK  145 

When  the  milk  supply  is  poor  the  need  of  sterilization  is  self-evident. 
Not  only  does  it  destroy  the  bacteria,  but  it  provides  for  the  children 
of  the  poor  a  milk  that  is  safe  to  be  used  in  hot  weather,  and  requires 
\'ery  little  intelligence  or  time  for  its  preparation  or  subsequent  care. 
Even  for  sterilization,  however,  as  clean  a  milk  as  possible  should  be 
procured,  since  the  spore-bearing  bacteria  are  not  destroyed;  they 
may,  when  they  develop,  act  upon  the  protein  of  the  milk  and  not 
upon  the  milk  sugar.  Such  milk  may  be  capable  of  producing  severe 
toxic  symptoms,  and  yet  be  considered  safe,  since  it  may  not  be  sour. 
Sterilization  tends  largely  to  prevent  the  appearance  of  casein  curds 
in  the  stools;  but,  if  already  present,  it  is  one  of  the  best  methods 
for  getting  rid  of  them. 

Sterilization  makes  it  possible  to  feed  cow's  milk  to  a  large  number  of 
children  among  the  poor  who  would  otherwise  be  made  ill  by  the  milk, 
consequently  are  fed  on  poor  substitutes,  such  as  barley  water,  albumin 
water,  condensed  milk,  and  proprietary  infant  foods. 

Yet  this  process  is  advisable  only  when  the  milk  supply  is  unsatis- 
factory, as  it  produces  changes  within  it  that  are  undesirable,  and  all 
its  protective  properties,  such  as  ferments,  alexins,  antitoxins,  and 
agglutins  are  destroyed.  The  taste  of  the  milk  is  altered,  and  on  this 
account  some  infants  will  not  take  it  readily.  It  is  also  more  con- 
stipating; but,  as  sterilized  milk  is  usually  given  in  summer,  this  is  of 
little  consequence.  The  milk  sugar  is  partly  changed  into  caramel, 
the  lecithin  and  nuclein  are  decomposed,  the  organic  forms  of  phos- 
phorus are  reduced,  the  lactalbumin  is,  at  least,  partially  coagulated, 
the  emulsion  of  the  fat  is  altered,  the  action  of  rennet  upon  the  casein 
is  affected,  and  oxygen,  nitrogen,  and  carbonic  acid  gases  are  expelled. 
In  a  considerable  proportion  of  the  cases  scurvy  has  been  shown  to 
have  developed  in  children  fed  on  sterilized  milk. 

Pasteurization. — In  order  to  avoid  the  disadvantages  of  sterilization, 
and  at  the  same  time  obtain  all  the  benefits  Avhich  it  affords,  a  tem- 
perature was  sought  which  would  be  below  the  boiling  point,  212°  F., 
and  yet  would  destroy  pathogenic  and  other  bacteria.  It  has  been 
positively  demonstrated  that  pasteurization,  or  the  heating  of  milk 
to  150°  to  157°  F.  (65°  to  69°  C),  will  accomplish  this.  The  milk  is 
kept  at  this  temperature  for  twenty  to  thirty  minutes.  It  is  then 
cooled  rapidly  by  placing  the  bottles  in  cold  running  water,  and  they 
are  then  immediately  placed  on  ice  or  in  a  refrigerator,  so  that  the 
temperature  will  not  rise  above  45°  F. 

Pasteurization  produces  no  important  chemical  or  biological  change 
in  the  milk,  and  its  taste  is  very  little  changed.  The  pathogenic  and 
other  bacteria  in  the  pasteurized  milk  are  destroyed,  but  the  spores 
are  not.  The  lactic  acid-producing  bacteria,  which  cause  the  souring 
of  milk,  and  are  present  in  considerable  numbers  in  fresh  milk,  are 
also  destroyed,  consequently  the  tendency  of  pasteurized  milk  to  sour 
is  lessened.  The  presence  of  the  lactic  acid  group  also  tends  to  prevent 
the  development  of  other  bacteria. 

In  pasteurized  milk  the  lactic  acid  bacteria  are  destroyed,  but  the 
10 


146 


INFANT  FEEDING 


development  of  the  spores  is  not  checked  or  hmdered  by  either  the 
pasteurization  or  lactic  acid,  and  the  development  of  these  spores  is 
liable  to  proceed  unchecked.  It  is  important,  therefore,  to  use  pas- 
teurized milk  within  twent}'-four  hours,  as  the  destruction  of  the 
lactic  acid  group  prevents  the  milk  from  turning  sour,  and  also  favors 
the  development  of  spore-bearing  bacteria. 

The  putrefactive  group  that  affect  the  protein  may  develop  rapidly, 
yet  the  fact  that  the  milk  does  not  turn  sour  may  give  one  the  impres- 
sion that  it  is  safe  for  the  infant. 

The  best  method  of  pasteurizing  milk  is  by  the  use  of  the  Freeman 
pasteurizer.  This  is  uncomplicated,  reliable,  and  not  expensive,  and 
the  use  of  a  thermometer  insures  accuracy  in  the  temperature  to  which 
the  milk  is  raised.  During  the  hot  summer  months  pasteurization  is 
an  additional  protection  to  the  infant,  but  it  should  be  done  in  the 
home  of  the  child ;  since  if  milk  is  pasteurized  at  the  farm,  twenty-four 
hours  before  it  reaches  the  consumer,  the  dangers  to  the  infant  may  be 
increased  rather  than  lessened. 


Fig.  22. — Freeman  pasteurizer. 


Fig.  23. — Freeman  pasteurizer, 
tacle  raised  for  coolinsc. 


Recep- 


Heating  does  not  destroy  the  toxins  that  may  be  present  in  the  milk, 
but  it  does  destroy  the  bacteria,  and  checks  their  subsequent  growth. 
Therefore,  it  is  not  safe  to  assume  that  either  pasteurization  or 
sterilization  compensates  for  uncleanliness,  or  can  make  an  unclean 
and  toxic  milk  safe  food  for  an  infant. 

Concerning  the  Feeding  of  Sterilized,  Pasteurized,  or  Raw  Milk. — The 
only  reason  for  sterilizing  or  pasteurizing  milk  is  because  it  is  feared 
that,  if  fed  to  the  infant  raw,  it  will  make  the  child  ill.  In  deciding  then, 
in  a  particular  case,  whether  the  milk  should  be  heated  or  not,  and,  if 
heated,  whether  it  should  be  pasteurized  or  sterilized,  the  question 
depends  primarily  on  certain  factors — the  freshness  of  the  milk  and  the 
number  of  bacteria  it  contains  when  it  reaches  the  consumer,  also 
whether  or  not  it  has  been  kept  at  45°  to  50°  F.,  and  the  probability 
of  its  contamination  after  it  reaches  the  consumer. 

Another  important  factor  is  whether  the  season  is  summer  or  winter. 
Among  the  poor,  especially  in  cities,  the  milk  they  can  afford  to  buy 


COW'S  MILK  147 

is  always  twenty-four  hours  old,  contains  usually  a  large  number  of 
bacteria,  and  is  not  kept  at  a  low  temperature — 45°  to  50°  F. — after 
they  receive  it.  INIoreover,  if  their  surroundings  are  uncleanly,  the  risk 
of  contaminating  such  milk  is  very  great. 

Under  such  circumstances,  it  is  safer  for  the  infant  if  the  milk  is 
sterilized  for  one  hour,  and  this  can  be  accomplished  by  boiling  the 
milk  in  any  suitable  vessel,  preferably  a  double  boiler,  pouring  it  into 
a  clean  quart  jar,  corking  it  tightly,  and  keeping  it  in  the  coolest  place 
available.  Such  milk  will  keep  for  at  least  twenty-four  hours,  often 
longer,  and  is,  under  the  circumstances,  safer  than  when  pasteurized. 

When  infants  are  fed  for  any  considerable  period  on  sterilized  milk 
it  is  always  wise  to  give  them  a  small  amount  of  fresh  orange  juice 
every  day  or  two,  as  it  is  a  well  known  clinical  fact  that  many  cases  of 
scurvy  develop  in  infants  who  are  fed  on  sterilized  milk. 

In  the  feeding  of  infants  in  hot  weather  all  milk  that  is  not  "certified" 
should  be  pasteurized  except  when  the  supply  of  milk  is  produced 
close  to  the  consumer  and  under  exceptionally  sanitary  circumstances, 
is  cooled  immediately  after  milking,  and  receives  proper  care  after  it 
reaches  the  consumer. 

It  is,  in  my  opinion,  much  safer  in  hot  weather  to  pasteurize  all 
milk  concerning  which  there  is,  in  the  mind  of  the  physician,  the 
slightest  doubt.  The  heating  of  the  milk  to  157°  F.  practically  makes 
no  change  in  its  chemical  or  biological  composition,  and  children 
digest  it  well,  and  show  a  satisfactory  gain  in  weight  and  development. 
It  must  be  remembered,  however,  that  pasteurized  milk  should  not  be 
kept  longer  than  twenty-four  hours,  and  must  always  be  kept  cool. 
It  is  true  that  at  a  temperature  of  70°  C.  a  portion  of  the  lactalbumin 
and  lactoglobulin  is  coagulated,  but  the  nutritive  value  of  such  change 
is  apparently  very  slight. 

The  sterilization  or  pasteurization  of  milk  destroys  the  pathogenic 
bacteria  of  tuberculosis,  typhoid  fever,  and  diphtheria,  also  the 
streptococcus,  staphylococcus,  and  bacillus  coli  communis.  It  is  also 
of  assistance  in  the  treatment  of  the  gastro-intestinal  infections  of 
infants  and  children.  It  does  not,  however,  lessen  in  any  degree  the 
necessity  of  properly  modifying  the  milk  to  adapt  it  to  the  age  and 
digestive  capabilities  of  the  infant. 

When  May  an  Infant  be  Fed  Raiv  Modified  Milkt — Personally,  I 
feed  many  infants  on  raw  modified  milk  in  summer  as  well  as  in  winter. 
If  a  "certified  milk"  is  accessible,  and  one  is  sure  that  this  certified 
milk  is  only  twenty-four  hours  old,  or  even  less,  and  has  been  kept  at 
45°  to  50°  F.  or  lower  since  it  left  the  dairy;  if  the  consumer  can  give 
this  milk  the  best  care  as  to  home  modification,  icing,  and  freedom  from 
contamination,  then  I  see  no  reason  why  the  infant  should  not  be  fed 
on  raw  certified  modified  milk.  Among  the  intellligent  and  well-to-do 
the  importance  of  a  clean,  fresh  milk  with  low  bacterial  count  is  quite 
generally  appreciated;  and,  if  the  mother  is  properly  instructed  by 
the  physician,  the  results  of  such  feedings  are  very  satisfactory.  If, 
however,  there  is  any  doubt  that  the  various  steps  in  the  preparation 


148  INFANT  FEEDING 

and  care  of  this  milk  will  not  be  properly  carried  out,  then  it  is  much 
safer,  even  with  certified  milk,  to  pasteurize  it,  particularly  in  summer. 

Peptonization. — Peptonized  milk  is  of  service  when  an  infant  is 
unable  to  digest  sufficient  milk  to  make  it  gain  in  weight.  It  must  not 
be  understood  that  every  child  that  does  not  gain  in  weight  should  be 
fed  on  peptonized  milk;  but  by  its  use  a  larger  amount  of  food  may 
often  be  given,  and  the  digestion  and  absorption  of  this  food  be 
rendered  less  difficult  for  the  stomach  and  intestines. 

The  object  of  peptonizing  is  partially  or  completely  to  digest  the 
protein  before  feeding,  consequently  to  give  the  child  a  higher  protein 
percentage  than  would  be  possible  without  its  use.  One  may  use  the 
peptonizing  tubes  on  the  market,  which  contain  five  grains  of  the 
extract  of  pancreatin  and  fifteen  grains  of  bicarbonate  of  soda,  or  may 
order  this  amount  put  up  in  waxed  paper  powders. 

If  one  of  the  powders  is  dissolved  in  four  ounces  of  cold  water,  and 
this  added  to  one  pint  of  fresh  milk  which  is  placed  in  water  at  a  tem- 
perature of  110°  F.,  peptonization  begins  at  once,  and  may  be  con- 
tinued as  long  as  desired  for  each  individual  child.  If  the  milk  is 
removed  after  twelve  minutes,  and  immediately  placed  on  ice,  further 
peptonization  is  checked,  and  the  milk  is  unaltered  in  taste.  If  kept 
in  the  warm  water  for  twenty  (20)  minutes,  it  usually  becomes  so 
bitter  that  many  infants  will  not  take  it  readily. 

Peptonization  does  not  interfere  in  any  way  with  the  modification 
of  the  milk,  or  make  it  undesirable  or  unnecessary  to  use  modified 
milk.  The  amount  of  peptonizing  powder  added  is  regulated  by  the 
amount  of  milk  used  at  each  feeding.  Since  peptonization  takes  place 
only  in  an  alkaline  medium,  the  bicarbonate  of  soda  must  always 
be  added.  This  milk  is  useful  in  premature  and  delicate  infants  as 
an  aid  to  digestion,  also  in  convalescence  from  acute  and  chronic 
gastro-intestinal  diseases,  when  it  is  desirable  to  give  the  infant  milk, 
and  one  more  or  less  doubts  its  ability  to  digest  it. 

It  is  often,  in  my  experience,  possible  to  give  the  infant  so  fed  a 
larger  amount  of  milk  if  it  is  partially  peptonized,  then  if  there  is  a  gain 
in  weight  the  amount  of  powder  can  be  gradually  reduced  until,  in 
the  course  of  a  few  weeks,  it  may  be  entirely  omitted.  The  fact  that 
the  digestive  organs  of  an  infant  will  develop  and  acquire  the  power 
perfectly  to  digest  cow's  milk,  if  the  infant  is  healthy  and  properly 
fed,  is  well  known,  and  this  fact  is  often  used  as  an  argument  against 
peptonization,  which  reduces  the  normal  work  of  digestion;  but  pep- 
tonization is  advised  only  in  those  cases  where  the  digestion  of  the 
child  is  temporarily  poor,  and  as  the  child  improves  it  is  gradually 
discontinued. 

Completely  to  peptonize  modified  milk  requires  that  the  bottles 
be  kept  in  w^ater  at  a  temperature  of  110°  F.  for  one  hour.  This  milk 
may  be  used  in  feeding  by  gavage  those  infants  who  can  not,  or  will 
not,  take  enough  food  properly  to  nourish  them. 

In  giving  nutrient  enemata  to  infants,  skimmed  milk  should  be  used. 
A  linen  or  silk  catheter,  full  rnale  size,  should  be  well  oiled  and  gently 


COW'S  MILK  149 

passed  al)()ut  7  or  8  inches  up  the  rectuiii,  and  tlie  milk,  at  a  tempera- 
ture of  100°  ¥.,  be  allowed  to  How  gently  into  the  bowel.  About  the 
same  amount  of  food  should  be  given  by  rectum  as  would  be  suitable 
for  a  bottle  feeding;  this  amount,  of  course,  depending  on  the  age  of 
the  infant. 

The  child  should  lie  on  the  left  side  with  the  buttocks  elevated,  and, 
if  possible,  the  enemata  should  be  given  without  causing  any  fright  or 
nervousness.  Thej^  should  not  be  repeated  oftener  than  every  six  or  eight 
hours,  and  while  they  are  being  given  the  lower  bowel  should  be  irri- 
gated once  daily  with  normal  salt  solution.  As  a  rule,  this  method  of 
feeding  cannot  be  continued  more  than  a  week  or  ten  days,  as  the 
rectum  is  apt  to  become  irritable  and  the  enema  is  quickly  expelled. 

Diluents — Water. — In  order  to  reduce  the  4  per  cent,  protein  in 
cow's  milk  to  a  percentage  that  the  infant  is  able  to  digest,  it  is  neces- 
sary to  add  to  the  milk  a  diluent,  and  the  most  common  diluent  is 
water.  The  amount  of  water  can  be  regulated  so  as  to  produce  any 
desired  reduction  in  the  protein.  The  protein  of  cow's  milk  is  not 
only  greatly  in  excess,  as  compared  with  breast  milk,  but  the  protein 
in  cow's  milk  has  a  tendency  to  form  large  curds  in  the  infant's  stomach, 
and  these  are  more  difficult  to  digest  than  the  finer  flocculi  produced  by 
the  protein  in  human  milk. 

Cereal  Diluents. — Cereal  decoctions  act  mechanically,  and  break 
the  coagulable  proteins  up  into  finer  particles  than  is  usual  when  plain 
water  is  added.  Any  of  the  cereal  decoctions,  as  prepared  on  page  157, 
may  be  used,  and  by  reference  to  this  table  one  may  see  exactly  the 
amount  of  starch  that  is  to  be  added.  If  the  infant  is  young,  dextrinized 
gruels  are  preferable,  as  the  functions  of  the  salivary  glands  and 
pancreas,  which  are  only  partially  established  in  the  young  infant, 
are  thus  compensated  for. 

The  preparation  of  dextrinized  gruel  is  very  simple.  A  teaspoonful 
of  liquid  diastase,  or  five  grains  of  taka  diastase  added  to  a  quart  of 
any  of  the  cereal  gruels  after  they  have  been  prepared,  converts  the  raw 
starch  into  soluble  carbohydrates.  The  cereal  decoction  should  be 
stirred  after  the  diastase  is  added,  and  as  the  starch  becornes  dextrin- 
ized the  gruel  becomes  thinner.  The  diastase  is  added  after  the 
gruel  has  cooled  sufficiently  to  be  tasted.  After  it  becomes  thin  by 
the  addition  of  the  diastase,  it  should  be  strained,  and  then  kept 
cold. 

One  of  the  best  preparations  of  diastase  to  use  for  dextrinizing 
gruels  is  called  cereo.  Half  a  teaspoonful  of  cereo  is  sufficient  for  one 
pint  of  gruel.  In  the  infant  of  six  months  or  older  the  starch  digestive 
function  is  sufficiently  developed  to  render  dextrinization  unnecessary. 
The  most  common  form  of  gereal  diluent  is  barley  water,  and,  if  there 
is  any  vomiting  br  diarrhea,  it  is  the  one  to  be  preferred.  Oatmeal 
water,  being  slightly  laxative,  is  to  be  selected  if  there  is  constipation. 
The  digestion  of  protein  is  rendered  less  difficult  by  the  addition  of 
cereal  diluents,  probably  owing  to  the  finer  protein  curds  which  they 
form. 


150  INFANT  FEEDING 

Alkaline  Diluenix.  The  alkaline  diluents  commonly  used  are  lime- 
water  and  bicarbonate  of  soda  water.  It  is  a  matter  of  clinical 
experience  that  the  addition  of  either  of  these  alkalies  is  of  ser\-ice 
in  infant  feeding,  and  their  beneficial  effect  is  due  to  the  fact  that  they 
tend  to  retard  the  action  of  the  rennet  ferment  in  the  stomach  on  the 
casein.  Any  lactic  acid  which  may  be  present  in  the  milk  is  also 
neutralized  by  the  alkali  added,  and,  by  their  action  in  partly  neutral- 
izing the  normal  acids  of  the  stomach,  they  lessen  the  tendency  of  the 
casein  to  form  in  large  curds. 

Lime-water  is  the  alkaline  diluent  commonly  employed,  and  is 
usually  added  in  the  proportion  of  5  per  cent. — one  ounce  of  lime-water 
to  every  twenty  ounces  of  food  mixture.  The  effect  of  the  lime-water 
is  in  direct  proportion  to  the  amount  of  cow's  milk  in  the  food.  If  the 
percentage  of  milk  is  large,  the  effect  will  be  much  less  than  if,  as  in  the 
feeding  of  young  infants,  the  percentage  of  milk  is  small. 

Acting,  as  it  does,  on  the  protein  to  prevent  the  clotting  action  of 
rennet  in  the  stomach,  the  formation  of  clotted  paracasein  is  delayed, 
and  the  masses  formed  are,  therefore,  smaller.  It  is  evident  that, 
if  large  amounts  of  lime-water  are  added  to  very  weak  milk  mixtures, 
the  clotting  of  the  milk  in  the  stomach  is  largely  prevented,  and  the 
milk  will  pass  into  the  intestine  but  little  aflfected  by  the  acids  of  the 
stomach. 

Xext  to  lime-water,  bicarbonate  of  soda  is  the  alkali  most  commonly 
added  to  the  diluent,  usually  in  the  proportion  of  one  grain  to  each 
ounce  of  the  food  mixture.  If,  however,  it  is  added  in  the  proportion 
of  two  grains  to  each  ounce,  it  tends,  as  do  larger  amounts  of  lime-water, 
to  prevent  the  clotting  of  the  casein  by  delaying  acid  formation  in  the 
stomach. 

CONDENSED  MILK. 

Condensed  milk  consists  of  cow's  milk  which  has  been  first  sterilized, 
and  then  evaporated  in  a  vacuum.  Cane  sugar  is  then  added,  and  the 
preparation  is  hermetically  sealed  in  tin  cans,  or  sold  fresh  and 
unsweetened. 

Condensed  milk  contains,  even  when  diluted  with  six  parts  of 
water,  only  a  little  over  1  per  cent,  of  fat  and  protein,  and  more  than 
7  per  cent,  of  sugar.  In  feeding  young  infants  it  is  often  diluted  twelve 
or  fourteen  times  with  water,  so  that  all  of  these  percentages  are  reduced 
to  one-half  of  the  above.  Xow  if,  for  any  particular  reason,  it  is 
advisable  to  feed  an  infant  on  these  low  percentages,  condensed  milk 
may  be  used  with  advantage. 

It  is,  of  course,  at  once  apparent  that  condensed  milk,  being  so  weak 
in  fats  and  proteins,  is  poor  nourishment  for  an  infant.  The  child,  if 
fed  continuously  upon  it,  owing  to  its  ability  to  digest  sugar,  may 
gain  in  weight  and  become  quite  fat,  but  its  tissues  are  soft  and 
flabby,  it  cuts  its  teeth  late,  its  bones  fail  to  develop  properly,  it  is  late 
in  creeping  and  walking,  and  becomes  rachitic  and  anemic. 

The  great  objection  to  condensed  milk  is  that  (unless  one  bears  in 


THE   FOOD   MATERIALS    USED   IN  INFANT  FEEDING       151 

mind  tlie  necessity  of  a  proper  amount  of  fat  and  proteins  in  tlie 
diet  and  the  dangers  of  a  deficiency  (jf  these  food  materials)  because 
the  l)aby  looks  fat  and  well  it  may  be  allowed  to  remain  too  long  on  the 
condensed  milk.  Under  certain  circumstances,  as  a  temporary  food, 
condensed  milk  is  valuable. 

Among  the  poor,  especially  in  large  cities  where  it  is  impossible  for 
them  to  procure  good  milk,  or  when,  owing  to  ignorance  or  carelessness 
they  cannot  prepare  good  cow's  milk  properly  or  keep  it  after  its 
preparation,  condensed  milk  is  often  the  safest  and  best  food,  espec- 
ially during  the  hot  summer  months.  It  is  cheap,  easily  prepared, 
each  feeding  is  made  ready  at  the  time  of  feeding,  so  that  the  bottle 
and  nipple  can  be  cleaned  each  time,  and  it  is  sterile. 

It  is  also  often  very  satisfactory  for  young  infants  during  a  few  days 
when  travelling,  or  when  the  supply  of  fresh  cow's  milk  is  uncertain  or 
unsatisfactory,  and  it  is  of  use  sometimes  for  young  infants  who  are 
suffering  from  acute  indigestion,  especially,  in  my  experience,  when  they 
have  been  fed  excessive  amounts  of  fats,  and  are  suflFering  from  acute 
fat  indigestion.  Such  babies  usually  take  it  greedily,  owing  to  its  sweet 
taste,  and  it  is  often  retained  when  modified  cow's  milk  is  vomited. 

As  the  infant's  digestion  improves,  the  proportions  should  be 
gradually  reduced  from  twelve  parts  of  water  and  one  part  of  condensed 
milk  to  six  parts  of  water  and  one  part  of  condensed  milk;  cream 
should  then  be  added,  a  teaspoonful  to  each  feeding,  and  this  gradually- 
increased  to  a  tablespoonful  at  each  feeding,  and  then  the  infant  is 
placed  upon  weak  modified  milk  mixtures. 

THE  FOOD  MATERIALS  USED  IN  INFANT  FEEDING. 

An  infant  may  be  fed  in  one  of  three  ways:  By  its  own  mother, 
which,  if  she  has  a  suitable  supply  of  breast  milk,  is  to  be  preferred; 
by  a  wet  nurse,  which,  if  certain  precautions  are  taken  as  regards  her 
health  and  her  ability  to  secrete  a  normal  amount  of  breast  milk  of  a 
certain  quality,  is  undoubtedly  the  next  best  method;  or  the  child  may 
be  raised  on  the  bottle. 

The  raising  of  a  child  on  the  bottle  is  at  all  times  a  responsibility 
which  is  not  to  be  assumed  by  the  physician  unless  he  has  devoted 
much  time  and  thought  to  the  study  of  infant  feeding.  If  the  child  is 
placed  in  the  hands  of  a  skilled  pediatrist  immediately  after  birth,  or  as 
soon  as  it  is  decided  that  it  requires  food  other  than  breast  milk,  the 
difficulties  encountered  are  often  slight  and  the  disturbances  of  the 
gastro-intestinal  tract  are  usually  mild. 

If,  however,  it  is  poorly  nourished  and  has  had  more  or  less  severe 
gastro-intestinal  disturbances  for  weeks  or  months,  its  subsequent 
feeding  on  the  bottle  becomes  one  of  the  most  difficult  tasks  of  the 
pediatrist;  and  while  the  final  result  is  almost  invariably  favorable, 
one  must  expect  to  encounter,  during  the  period  of  feeding,  relapses 
and  setbacks  which,  being  looked  for,  will  not  discourage  the  physician 
who  has  thoroughly  studied  and  understands  his  subject. 


152  INFANT  FEEDING 

It  must  be  well  understood  at  the  outset  that  infant  feeding  is  a 
difficult  problem  and  that  it  is  a  very  broad  and  important  subject. 
It  includes  the  feeding  of  the  infant  in  sickness  and  in  health.  It  is 
intimately  connected  with  the  problems  of  etiology  and  diagnosis,  and 
is  linked  with  many  other  associated  factors,  as  heredity,  environ- 
ment and  fresh  air.  The  food  which  is  provided  by  each  mammal  for 
its  young  is  particularly  suited  to  develop  its  digestive  organs  as 
well  as  the  rest  of  its  body,  and  is  always  animal  and  never  vege- 
table. 

During  this  early  nursing  period  of  child  life,  it  seems,  therefore, 
normal  for  the  food  to  be  in  animal  and  not  vegetable  form.  It  is  also 
highly  important  that  the  digestive  powers  and  possibilities  of  the 
infant  be  carefully  studied  and  understood,  and  only  such  food  given 
as  the  child  is  able  to  digest.  It  is  important  to  remember  that  while 
cow's  milk  is  usually  the  best  artificial  food  for  an  infant,  it  was 
intended  for  the  stomach  of  the  calf  and  not  for  the  stomach  of  the 
infant.  It  is,  therefore,  safe  to  give  this  cow's  milk  only  after  the  power 
of  the  infant  to  digest  it  is  thoroughly  understood. 

Infant  feeding  is  one  of  the  most  important  departments  of  pediatrics. 
The  problem  is  not  alone  to  provide  suitable  food  in  the  proper  pro- 
portions to  sufficiently  nourish  the  infant,  but  it  is  important  that  all 
the  different  tissues  of  this  rapidly  growing  organism  be  appropriately 
nourished. 

The  infant's  increase  in  weight  and  length  is  so  unusual  as  compared 
with  any  other  period  of  life,  that  the  problem  of  its  feeding  differs 
radically  from  what  one  meets  with  in  adult  life.  The  adult  requires 
sufficient  food  to  keep  his  body  in  a  state  of  equilibrium.  The  young 
child  must  have  food  not  only  to  nourish  his  body,  but  an  extra  amount 
to  produce  the  very  remarkable  increase  in  growth  that  occurs  at  this 
period. 

Now  if  it  were  simply  a  question  of  giving  the  infant  a  large  amount 
of  milk,  the  matter  would  be  a  very  simple  one.  Unfortunately, 
instead  of  being  such  a  simple  task  as  this,  the  problem  is  often  a 
complex  one,  and  the  difficulties  are  much  increased  when,  instead  of 
being  fed  on  the  breast,  the  infant  is  being  raised  on  the  bottle. 
The  gastro-intestinal  apparatus  of  the  infant  is  extremely  delicate, 
complicated,  and  sensitive.  It  is  easil}^  disturbed  by  influences  that 
are  often  difficult  to  appreciate  and  guard  against,  and  if  any  disturb- 
ance of  digestion  is  allowed  to  continue  for  more  than  a  short  period, 
it  often  complicates,  to  an  excessive  degree,  the  question  of  its  food. 

The  study  of  infant  metabolism  clearly  shows  that  there  is  a  con- 
tinuous using  up  of  the  body  tissues,  and  that  to  replace  these  tissues 
and  in  addition  to  cause  an  increase  in  their  growth,  requires  that  the 
child  be  fed  not  only  a  certain  amount  of  food  which  it  can  digest, 
but  also  a  food  ration  so  well  balanced  that  the  different  require- 
ments of  the  various  tissues  may  be  so  amply  met  that  the  baby  will 
develop  along  well  established  and  normal  lines. 

To  produce  gain  in  weight  by  a  food  that  does  not  possess  the  proper 


THE  FOOD  MATERIALS    USED  IN  INFANT  FEEDING       153 

proportions  of  the  various  food  elements  must  always  be  considered  .as 
a  temporary  expedient,  perhaps  useful  and  necessary  for  the  time 
being,  but  never  to  be  persisted  in  long  enough  to  produce  anemia, 
malnutrition  or  rickets.  Unfortunately,  the  ill-effects  of  such  feeding 
may  not  be  apparent  for  weeks  or  months,  and  are  easily  overlooked, 
especially  if  the  child  is  gaining  in  weight.  Many  of  the  foods  of  this 
character  possess  a  high  percentage  of  carbohydrates  and  often  a  low 
proportion  of  fat  and  protein. 

If  there  is  one  factor  in  infant  feeding  that  is  more  important  than 
another,  it  is  the  appreciation  of  the  fact  that  the  regular  nourish- 
ment of  the  infant  must  contain  certain  food  elements  in  more  or  less 
definite  proportions.  These  proportions  are  not  absolutely  fixed 
percentages,  but  they  can  vary  only  within  certain  broad  limits,  and 
it  is  most  unwise  either  greatly  to  reduce  one  or  markedly  increase 
another  food  element,  unless  there  be,  temporarily,  some  very  good 
and  sufficient  reasons. 

There  are  certain  laws  of  physiology  which  make  it  imperative  that 
a  definite  amount  of  food  be  given  the  infant,  and,  further  than  this, 
the  food  must  be  composed  of  fairly  accurate  amounts  of  the  different 
food  ingredients.  If  the  principles  that  underlie  infant  feeding  are 
well  understood  and  adhered  to,  many  of  the  more  common  errors  of 
feeding  will  be  avoided. 

The  child's  body  is  composed  of  protein,  fat,  water  and  mineral 
salts,  and  is  constantly  undergoing  a  process  of  waste.  This  loss  must 
be  replaced  by  the  food  elements,  and  the  principles  of  nutrition  that 
underlie  the  replacing  in  the  child's  body  of  this  continuous  using  up 
of  its  own  body  cells,  are  the  first  facts  of  infant  feeding  which  the 
student  and  physician  must  appreciate.  It  is  important,  therefore, 
that  we  understand  the  part  that  the  different  food  elements  perform 
in  the  replacing  of  the  loss  of  the  body  tissues.  These  food  elements 
are  water,  protein,  fat,  carbohydrates,  and  mineral  salts. 

Water. — The  infant's  body  is  composed  of  about  68  per  cent,  of  water, 
and  it  is,  therefore,  only  natural  that  in  building  up  this  infant's  body, 
or,  in  fact  the  body  of  any  young  mammal,  a  large  percentage  of 
the  nourishment  taken  should  consist  of  water.  The  various  food 
elements  are  dissolved  or  suspended  in  this  water  and  the  food  is 
consequently  always  in  a  liquid  form.  The  water  also  serves  the 
important  function  of  eliminating  the  waste  products  of  the  infant's 
economy,  and  it  is  estimated  that  to  meet  the  various  demands  of  the 
infant,  five  times  as  much  water  is  required,  in  proportion  to  its  weight, 
as  is  needed  by  the  adult.  The  common  practice  of  giving  a  child 
water  to  drink  between  its  feedings,  especially  in  summer,  is,  therefore, 
a  good  one. 

During  illness,  when  the  amount  of  fluids  lost  by  the  body  is  great, 
or  when  toxemia  exists,  the  administration  of  large  quantities  of  water 
is  most  important.  In  fact,  water,  being  present  in  such  a  very  large 
proportion  in  both  human  and  cow's  milk — 86  to  87  per  cent. — is 
evidently  the  most  important  single  food  ingredient,  and  if  it  can  be 


154  INPANT  FEEDING 

given  in  fairly  large  quantities  will  assist  materially  in  niaintainiiig 
body  weight,  especially  in  gastro-intestinal  disease. 

The  absence  of  the  other  food  elements  for  more  than  a  few  days  is, 
however,  a  great  disadvantage  to  the  body  tissue,  and  results  in  their 
rapid  wasting.  The  water  carries  the  nourishment,  by  the  various 
blood  and  lymphatic  vessels,  to  every  organ  and  tissue  in  the  body,  and 
by  carrying  off  waste  products  through  the  skin,  bowels,  kidneys  and 
breath,  prevents  the  development  of  auto-intoxication. 

Protein. — Protein  is  an  important  element  in  the  food,  and  is  that 
portion  of  the  diet  which  replaces  the  nitrogenous  waste  of  the  tissues. 
It  is  also  that  element  in  the  diet  that  is  capable  of  building  up  new 
cells  in  the  various  organs  and  tissues,  and  as  the  growth  of  the  infant's 
body  is  unusually  rapid  a  proper  amount  of  protein  is  absolutely 
essential  if  this  growth  is  to  be  maintained. 

In  order  that  the  protein  may  be  utilized  for  its  purpose  of  cell- 
building,  it  is  necessary  that  the  fats  and  carbohydrates  be  given  in 
sufficient  amount  to  produce  all  the  heat  and  energy  that  the  infant's 
body  may  require.  If  this  requisite  amount  of  carbohydrates  and  fats 
is  not  given,  an  excessive  amount  of  protein  is  necessary  to  produce 
the  bodily  heat  required. 

By  supplying  this  fat  and  carbohydrate  in  the  diet,  not  only  is  the 
normal  animal  heat  of  the  body  preserved,  but  they  make  it  unneces- 
sary for  the  protein  to  furnish  this  energy  and  heat,  and  the  protein  is 
then  capable  of  performing  its  normal  function  of  cell  upbuilding. 

There  is,  however,  a  decided  difference  between  the  protein  of  human 
milk  and  cow's  milk.  Human  milk  contains  1.5  per  cent,  protein, 
of  which  lactalbumin  forms  from  one-half  to  two-thirds  of  the  total 
protein.  Cow's  milk  contains  3.5  per  cent,  protein,  of  which  casein 
forms  two-thirds  of  the  total  protein.  It  is  at  once  evident  that  not 
only  is  the  protein  present  in  much  larger  amounts  in  cow's  milk  than 
in  human  milk,  but  the  proportion  of  casein  is  also  much  greater. 

It  has  been  shown  by  Chapin  that  each  mammal  furnishes  an 
animal  food  which  is  peculiarly  adapted  to  the  digestive  organs  of 
its  young,  therefore  we  can  not  doubt  that  the  lactalbumin  in 
mother's  milk  is  easier  for  the  infant  to  digest  than  is  the  casein 
of  cow's  milk.  It  is,  however,  equally  true  that  we  have  formerly 
exaggerated  the  difficulties  that  infants  have  in  digesting  casein,  and 
that  it  is  not  nearly  so  hard  for  the  infant  to  digest  it  as  we  formerly 
supposed. 

In  fact,  it  is  not  difficult  for  the  infant  stomach  to  digest  cow's 
casein,  if  it  is  not  thrown  down  in  the  stomach  in  large  clots.  If  this 
large  clot  formation  can  be  prevented,  cow  casein  is  digested  by  the 
infant  with  very  little  difficulty.  This  can  be  accomplished  by  adding 
to  the  cow's  milk,  before  it  is  given  to  the  infant,  an  alkali,  as  lime 
water  or  bicarbonate  of  soda,  or  an  acid,  as  dilute  hydrochloric  acid. 
Either  the  acid  or  the  alkali  will  combine  with  the  casein  and,  since 
rennet  can  act  only  in  a  slightly  acid  medium,  will  prevent  the  casein 
from  forming  large  clots. 


THE  FOOD   MATERIALS    USED   IN  INFANT  FEEDING       155 

Fats. — Til  the  liealthy  l)rcast-fe(l  or  hottlr-tVd  ii)faMt,  fat  is  always 
Found  in  the  stools,  and  its  presence  renders  the  stools  less  hard  and 
dry.  The  total  amount  of  fat  in  the  food  of  the  infant  at  the  breast 
is  not,  therefore,  utilized  entirely  for  its  food  value.  A  certain  amount 
of  fat  cleavage  begins  in  the  stomach,  and  fatty  acids  and  soluble  soaps 
are  produced  in  the  intestinal  canal. 

The  bile  affords  a  medium  for  the  solution  of  free  fatty  acids,  and, 
to  a  certain  extent  at  least,  fats  are  transformed  into  soluble  forms 
before  being  absorbed.  The  rapidly  growing  infant  requires  a  pro- 
portionately larger  amount  of  fat  than  does  the  older  child  or  adult. 
This  fat,  which  in  human  and  cow's  milk  is  present  in  the  proportion 
of  4  per  cent.,  has  a  very  complex  composition. 

Moreover,  fat  metabolism  is  a  complicated  process  which  is  not  yet 
perfectly  understood.  There  is  a  decided  difference  in  the  composition 
of  human  milk  and  cow's  milk,  and  cow's  milk  is  more  difficult  for  the 
infant  to  digest  than  human  milk.  Cow's  milk  contains  a  smaller 
percentage  of  oleic  acid  and  a  larger  percentage  of  volatile  fatty  acids 
than  does  woman's  milk. 

The  caloric  values  of  the  fat,  protein  and  carbohydrates,  according  to 
Rubner,  are  as  follows : 

1  gram  of  protein  yields  4.1  calories. 

1  gram  of  fat  yields  9.3  calories. 

1  gram  of  carbohydrate  yields  4.1  calories. 

It  is  thus  evident  that  fats  are  the  chief  source  of  animal  heat,  since 
their  caloric  value  is  double  that  of  either  proteins  or  carbohydrates. 
Although  we  must  appreciate  the  fact  that  while  fat  is  always  present 
in  the  nursing  infant's  stools,  only  a  portion  of  the  fat  in  the  food  is 
utilized  in  metabolism.  Fats  do  not  build  up  the  cells  of  the  body  as 
does  the  protein,  but  the  fats  and  carbohydrates,  by  supplying  the 
animal  heat  and  energy  to  the  body,  save  nitrogenous  waste  and  allow 
the  protein  metabolism  to  be  used  for  the  growth  and  repair  of  the  cells 
of  the  various  organs  and  tissues. 

Fat  deposits  are  found  beneath  the  skin  over  practically  the  entire 
body  surface  and  have  an  important  function  in  increasing  the  body 
weight.  They  are  also  an  evidence  of  health;  a  healthy  baby  is  always 
a  moderately  fat  baby.  This  fat  supply  is  a  valuable  source  of  heat 
and  energy  during  an  illness  when  the  supply  of  fat  ingested  may  be 
much  below  normal. 

The  nervous  system,  which  shows  such  remarkable  growth  during 
infancy  and  which  is  composed  largely  of  fat,  requires  a  large  amount 
of  fat  for  its  normal  development.  This  is  clearly  shown  in  the  impaired 
development  of  the  nervous  system  if  either  the  proportion  of  fat  in 
the  food  is  too  small,  or  the  child  is  suffering  from  prolonged  fat  indi- 
gestion. Fat  also  plays  an  important  part  in  bony  development,  and 
rickets  is  often  the  result  of  fat  starvation.  Malnutrition  and  anemia 
are  common  conditions  due  to  either  too  little  fat  in  the  food,  or  to 
poor  fat  digestion. 

The  importance  of  fat  in  the  diet  of  the  infant  may,  howcA'er,  lead 


156  INFANT  FEEDING 

to  its  l)einfi;  given  in  excessive  amounts.  It  should  never  exceed  4  per 
cent,  in  a  milk  mixture,  and  should  always  be  reduced  below  the  normal 
or  usual  amount  for  the  age  of  the  infant  in  acute  gastro-intestinal 
diseases  and  febrile  conditions;  as  infants  with  malnutrition  are  very 
apt  to  suffer  from  fat  indigestion,  the  amount  of  fat  in  the  food  must 
be  cautiously  increased. 

Carbohydrates. — The  carbohydrates  in  the  form  of  milk  sugar  are 
present  in  human  milk  in  the  proportion  of  7  per  cent.,  and  as  milk 
sugar  in  cow's  milk  in  the  proportion  of  4  per  cent.  The  percentage  of 
milk  sugar  in  both  human  and  cow's  milk  does  not  vary  to  any  appreci- 
able amount  during  the  period  of  lactation.  Moreover,  a  chemical 
analysis  of  the  sugar  contained  in  human  and  cow's  milk  fails  to  show 
any  differences  that  are  of  importance,  and,  further  than  this,  the  sugar 
in  the  milk  of  all  mammals  is  this  same  milk  sugar. 

In  the  feeding  of  cow's  milk  to  infants,  the  regulation  of  the  sugar 
content  is  brought  about  by  simply  adding  the  required  amount  of 
milk  sugar  to  the  cow's  milk  mixture.  Milk  sugar  is  less  liable  to 
undergo  fermentation  in  the  infant's  stomach  than  is  cane  sugar  or 
maltose.  All  three  varieties — cane  sugar,  maltose  and  milk  sugar — 
easily  undergo  fermentation  in  the  intestines. 

It  is  a  matter  of  clinical  experience,  however,  that  the  milk  sugar 
of  cow's  milk  is  especially  liable  to  fermentative  changes  in  the  intes- 
tines. This  is  supposed  to  be  due  to  the  fact  that  the  milk  sugar 
contained  in  the  whey  protein  of  cow's  milk  is  rendered  less  easy  of 
digestion  and  assimilation;  hence  its  greater  tendency  to  fermentation. 

The  carbohydrates  represent  the  largest  proportion  of  solids  in 
human  milk,  and  whether  the  infant  be  given  carbohydrates  in  the 
form  of  milk  sugar,  maltose,  or  cane  sugar,  the  percentage  is  usually 
the  same,  unless  it  is  reduced  because  the  infant  has  sugar  indigestion. 
All  three  forms  of  sugar  are  changed  into  glucose  by  the  digestive 
fluids. 

The  newborn  infant  has  very  little  ability  to  digest  starch,  and 
starch  should  not,  as  a  rule,  be  added  to  the  diet  until  the  infant  is 
six  months  old.  After  this  age,  the  starch-digesting  ability  of  the 
infant  rapidly  increases,  and  many  bottle-fed  infants  are  given  starch 
in  their  food,  after  the  eighth  or  ninth  month.  If  one  decides  to  give 
the  baby  some  starch,  it  is  absolutely  necessary  that  the  percentage 
of  carbohydrates  added  to  the  food  by  this  starch  be  exactly  known. 
The  addition  of  the  starch  adds  no  fat  to  the  food  and  only  a  very 
minute  amount  of  protein. 

The  amount  of  starch  in  the  different  gruels  varies  according  to  the 
cereal  employed,  and  whether  the  whole  grain,  cracked  grain,  or  flour 
is  used.  Cereo  gruel  flour  can  now  be  purchased,  and,  by  adding  a 
certain  amount  of  this  flour  to  a  fixed  proportion  of  water,  definite 
amounts  of  starch  can  be  added  to  the  infant's  food. 

It  cannot  be  too  strongly  emphasized  that  while  starch  is  often 
advantageously  added  to  the  infant's  diet,  it  should  be  added  with 
the  same  acciu'acy  as  in  adding  to  the  fat  or  protein  in  the  mixture, 


THE  FOOD  MATERIALS    USED  IN  INFANT  FEEDING       157 

and  as  breast  milk  contains  7  per  cent,  carbohydrates,  starch  should 
not  be  added  to  the  cow's  milk  mixture  in  such  amount  as  to  raise 
the  carbohydrates  above  this  7  per  cent. 

By  the  use  of  the  standardized  flours,  it  is  possible  to  know  the  exact 
percentage  of  the  proteins  and  carbohydrates  added,  and,  knowing 
the  exact  percentage  of  the  added  gruel,  one  can  easily  calculate  the 
amount  of  protein  and  carbohydrates  which  the  gruel  adds  to  the  milk 
mixture : 

PERCENTAGE  OF  PROTEINS  AND  CARBOHYDRATES  OBTAINED  BY  THE 
USE  OF  STANDARDIZED  FLOURS. 


Oat  and  barley. 

Legume. 

Wheat. 

Pro- 
teins. 

Carbo- 
hydrates 

Pro- 
teins. 

Carbo- 
hydrates 

Pro- 
teins. 

Carbo- 
hydrates 

1  level  tablespoonful  to  1  quart  water 

2  level  tablespoonfuls  to  1  quart  water 

3  level  tablespoonfuls  to  1  quart  water 
1  level  coverful  (1    ounce)    to    1    quart 

water 

0.12 
0.24 
0.36 

0  48 

0.60 
1.20 
1.80 

2.40 

4.80 

7.20 

9.60 

0.19 
0.39 
0.58 

0.78 

1.56 

2.34 

3.12 

0.53 
1.06 
1.59 

2.12 

4.24 

6.36 

8.48  . 

0.10 
0.20 
0.30 

0.40 

0.80 

1.20 

1.60 

0.62 
1.25 

1.88 

2  50 

2  level  coverfuls  (2  ounces)  to  1  quart 
water 

0.96 

5  00 

3  level  coverfuls  (3  ounces)  to  1  quart 
water .      . 

1  44 

7  50 

4  level  coverfuls  (4  ounces)  to  1  quart 
water 

1.92 

10  00 

The  carbohydrates  are  easy  of  digestion  and  for  this  reason  are 
popular  as  infant  foods.  They  are,  however,  as  previously  mentioned, 
liable  to  undergo  fermentation,  and  hence  carbohydrate  indigestion 
is  not  uncommon.  Infants  fed  on  carbohydrates  often  increase  rapidly 
in  weight,  but  the  flesh  is  soft  and  flabby  and  the  infant  is  deficient 
in  vitality  and  strength,  and  may  be  rachitic. 

The  carbohydrates  have  an  equal  heat-producing  power  with  the 
proteins.  They  are,  to  a  certain  extent,  converted  into  fats,  and  so 
have  a  tendency  to  add  to  the  infant's  weight.  .They  can  not  build  up 
the  cells  of  the  body  as  does  the  protein,  but  by  helping  to  maintain 
the  body  heat,  storing  up  fat  and  supplying  energy  to  the  body  cells, 
they  are  of  great  assistance  to  the  protein. 

"The  ordinary  soluble  carbohydrates  are  utilized  to  a  high  degree 
by  the  animal  organism"  (Hawk);  and  if  the  amount  given  is  not 
above  the  power  of  the  individual  to  assimilate,  about  97  per  cent,  is 
utilized.  The  amount  of  cellulose  utilized  by  the  human  digestive 
apparatus  is  "too  small  for  it  to  play  a  role  of  importance  in  the  diet 
of  a  normal  individual"  (Swartz).  There  is  probably  no  formation  of 
glycogen  or  sugar  from  ingested  cellulose. 

Mineral  Salts. — The  rapid  growth  of  all  the  tissues  and  organs  of  the 
infant,  especially  of  the  bones,  renders  the  ingestion  and  absorption 
of  the  mineral  salts  of  great  importance. 

Potassium,  sodium,  calcium,  magnesium,  phosphorus,  and  a  trace 


158  INFANT  FEEDING 

of  iron  are  the  most  important  mineral  salts  found  in  milk.  These 
salts,  with  the  exception  of  iron,  are  present  in  sufficient  amounts  in 
both  human  and  cow's  milk  to  supply  to  the  infant  all  that  its  body 
requu'es  for  normal  growth  and  development.  They  are  not,  however, 
as  a  rule,  found  in  sufficient  quantities  in  the  various  foods  often 
substituted  for  human  or  cow's  milk. 

The  deficiency  of  iron  in  the  milk  is  compensated  by  the  reserve 
store  of  iron  which  is  found  in  the  body  of  the  infant,  especially  in  the 
liver  and  spleen.  The  adult,  in  proportion  to  its  weight,  has  only 
about  one-third  as  much  iron  in  the  liver  and  other  organs  of  the  body 
as  has  the  infant.  The  diet  of  the  infant  after  the  first  year  contains 
much  more  iron,  and  the  iron  requirements  of  the  older  child  are 
accordingly  supplied  by  the  food  as  the  quantity  stored  in  the  body 
has  been  largely  utilized. 

According  to  the  analyses  of  Harrington  and  Kennicutt,  the  mineral 
constituents  in  human  milk  are: 

Calcium  phosphate 23 .  87 

Calcium  silicate 1.27 

Calcium  sulphate 2.25 

Calcium  carbonate         .      .       .       . 2.85 

Magnesium  carbonate 3.77 

Potassium  carbonate 23.47 

Potassium  sulphate 8.33 

Potassium  chloride 12.05 

Sodium  chloride 21.77 

Iron  oxide  alumina ; 0.37 

100.00 

Calcium  phosphate  is  present  in  considerable  quantity  and  is  especi- 
ally necessary  for  the  formation  of  the  skeleton.  The  potassium  salts 
are  also  present  in  proportionately  large  amount,  and  are  especially 
utilized  in  the  muscular  tissue  and  red  blood  cells.  The  percentage  of 
chloride  of  sodium  is  also  large.  The  salts  are  an  absolutely  necessary 
part  of  the  infant's  food.  They  are  essential  for  the  performance  of  the 
numerous  functions  of  cell  activity  and  for  the  proper  development  of 
the  nervous  system. 

It  is  important,  therefore,  that  the  mineral  salts  be  given  in  such  form 
as  is  easily  appropriated  and  used  by  the  infant.  This  is  best  accom- 
plished by  feeding  the  child  either  human  or  cow's  milk.  Mineral 
salts  are  present  in  definite  amounts  as  important  elements  of  all  the 
fluids  of  the  body,  and  are  necessary  for  the  proper  performance  of 
circulation,  digestion,  absorption,  secretion,  and  excretion. 

Breast-feeding. — The  best  food  for  an  infant  is  the  milk  from  its 
mother's  breasts.  It  is  assumed,  of  course,  that  the  mother  is  reason- 
ably strong  and  in  fairly  good  health.  If  she  willingly  undertakes  the 
duty  of  nursing  her  baby,  it  is  of  advantage.  She  should  be  relieved 
as  far  as  possible  from  all  unnecessary  nervous  strain  and  should  use 
moderate  care  in  her  diet,  exercise,  and  sleep.  These  precautions  will 
all  tend  to  increase  the  quantity  and  improve  the  qualit}'  of  her  milk 
and  make  it  more  likely  that  she  will  successfully  nurse  her  baby. 


BREAST-FEEDING  159 

It  is,  therefore,  necessary  to  inform  the  young  mother  who  hopes 
and  expects  to  nurse  her  child  that  it  is  important  for  her  to  do  every- 
thing within  reason  to  preserve  her  physical  health  and  nervous 
energy,  as  otherwise  she  may  unintentionally  interfere  greatly  with 
her  ability  to  nurse.  After  an  experience  of  thirty  years  in  the  practice 
of  pediatrics;  I  am  persuaded  that  if  the  physician  is  an  enthusiast 
on  breast  feeding,  he  will  almost  always  be  able  to  convince  the  mother 
of  the  importance  and  necessity  of  nursing  her  baby. 

Breast-feeding  must  not  be  made  too  hard  a  task,  and,  occasionally, 
it  may  be  wise  to  provide  a  bottle  feeding  once  a  day,  for  even  a  very 
}'oung  nursing  infant.  This  allows  the  mother,  on  any  day  that 
she  may  desire  it,  a  few  consecutive  hours  for  amusement  or  social 
pleasure. 

Mammary  Gland. — ^The  secretion  of  milk  from  the  mammary  gland, 
if  the  gland  is  healthy  and  the  mother  not  disturbed  by  disease,  worry 
or  overwork,  will  almost  invariably  be  a  milk  well  adapted  to  the 
requirements  of  the  growth  and  development  of  the  baby. 

Its  delicate  mechanism,  as  yet  only  imperfectly  understood,  is  very 
easily  disturbed  by  illness,  pregnancy,  menstruation,  worry,  excessive 
fatigue,  errors  in  diet,  and  many  other  causes,  and  the  milk  secreted 
may  undergo  many  and  various  changes  which  may  temporarily  or 
permanently  lessen  its  value  as  a  food  for  the  infant. 

The  mammary  gland  is  a  self-regulating  apparatus  elaboratmg  a 
smaller  or  a  greater  supply  according  to  the  demands  of  the  infant. 
It  is  not  only  an  organ  of  secretion  but  also  an  organ  of  excretion.  It 
is  important  to  appreciate  that  certain  drugs  may  be  in  part  excreted 
by  breast  milk,  and  that  during  the  colostrum  period  the  milk  differs 
distinctly  from  the  milk  secreted  later. 

The  child  should  be  put  to  the  breast  as  soon  as  possible,  usually 
within  three  hours,  after  the  mother  has  recovered  from  the  strain 
and  exhaustion  of  her  labor.  This  early  nursing  accomplishes  several 
important  objects.  It  draws  out  the  nipples,  promotes  uterine  con- 
tractions in  the  mother,  and  tends  to  hasten  the  formation  of  milk 
in  the  breasts. 

Moreover,  there  is  always  in  the  infant  an  initial  loss  in  weight, 
which  means  a  corresponding  loss  in  vitality,  and  this  is  at  least  lessened 
by  giving  the  child  a  reasonable  amount  of  nourishment  during  the 
first  three  days.  During  the  first  twenty-four  hours  the  child  should 
be  applied  four  times  to  the  breast;  during  the  second  and  third 
twenty-four  hours,  six  times;  and  after  this  every  two  hours  from 
6  A.M.  to  10  P.M. 

It  is  true  that  during  the  first  two  days  the  child  receives  very  little 
milk,  and  this  colostrum  milk  differs  greatly  from  the  milk  secreted 
later;  but  I  certainly  believe  that  this  milk  must  be  of  nutritive  and 
protective  value,  otherwise  it  would  not  always  be  present.  If, 
during  this  preliminary  feeding,  the  child  is  extremely  restless  and  cries 
as  if  from  hunger  or  thirst,  sterile  w^ater  may  be  given  in  two  dram 
feedings  three  or  four  times  a  day. 


160  INFANT  FEEDING 

Frequency  of  Breast-feeding. — The  extremely  rapid  growth  of  the 
infant  and  the  necessity  of  food  to  compensate  for  repair  of  waste  due 
to  its  great  metaboHc  activities  necessitate  the  giving  to  the  infant 
of  more  food  proportionately  than  to  the  older  child  or  adult.  The 
infant  requires  110  calories  every  twenty-four  hours  during  the  first 
four  months  of  its  life  per  kilo  of  body  weight;  100  calories  during 
the  second  four  months  per  kilo;  and  during  the  third  four  months 
90  calories  per  kilo  of  body  weight. 

During  the  night  a  healthy  infant  should  ne^'er  be  awakened, 
but,  if  awake,  it  may  be  nursed  twice  at  night  during  the  first  six 
weeks,  between  the  age  of  six  weeks  and  three  months  once  or  twice 
each  night,  and  between  three  and  six  months  the  child  should  not 
receive  more  than  one  breast  feeding  between  10  p.m.  and  6  a.m.  If 
it  awakes  oftener,  it  should  be  given  a  bottle  of  water. 

A  normal,  healthy  infant — if  awakened  every  tw^o  hours  from  6  a.m. 
to  10  p.:\i.  during  the  first  six  weeks;  every  two  and  a  half  hours  from 
the  age  of  six  weeks  to  three  months ;  and  after  this,  every  three  hours 
— receives  during  the  day  a  large  amount  of  nourishment,  and  being 
awakened  so  often  its  sleep  is  more  or  less  disturbed.  It  is  only 
natural  that  this  baby  will  require  during  the  night — 10  p.m.  to  6  a.m. — 
very  little  food  and  a  good  many  hom'S  of  sleep. 

This  regularity  of  feeding  is  of  great  practical  importance;  it  secures 
regular  hours  of  sleep  for  the  mother,  baby  and  the  baby's  nurse,  and 
the  infant,  as  a  rule,  quickly  adapts  itself  to  this  routine  and  nurses 
willingly,  sleeps  well,  and  is  quiet  and  happy.  If  the  infant  so  fed  is 
kept  in  the  fresh  air,  not  picked  up  when  it  cries,  not  rocked  or  fussed 
with,  it  rarely,  unless  sick,  should  be  a  source  of  great  care  or  anxiety. 

Unfortunately,  this  systematic  life,  as  regards  feeding,  bathing, 
sleep,  fresh  air  and  exercise,  is  often  deliberately  broken.  The  baby 
becomes  nervous  and  fretful  and  cries  because,  having  become  accus- 
tomed to  petting  and  rocking,  it  misses  this  attention.  Such  a  baby 
may  easily  disturb  the  peace  and  routine  of  an  entire  household. 

The  infant  should  be  allowed  to  nurse  from  fifteen  to  twenty  minutes 
at  each  feeding,  the  time  being  equally  divided  between  both  breasts. 
Some  infants,  especially  if  robust  and  nursing  vigorously,  and  there  is  a 
plentiful  supply  of  breast  milk,  will  satisfy  their  hunger  in  less  time 
than  this.  An  infant  may,  however,  nurse  too  quickly  from  the  breast 
just  as  it  may  nurse  too  quickly  from  a  bottle,  and  it  is  advisable, 
in  such  cases,  to  interrupt  the  nursing  every  two  or  three  minutes  for 
a  period  of  one  minute. 

As  soon  as  the  infant  ceases  to  nurse,  it  should  be  removed  from  the 
breast,  unless  it  is  evident  that  it  has  taken  only  a  small  amount  of 
milk — too  small  an  amount  properly  to  nourish  it.  In  such  cases,  the 
nipple  should  be  moved  gently  in  the  child's  mouth,  which  may  stimu- 
late it  to  niu-se.  The  child  should  never,  however,  be  allowed  to  lie 
with  the  nipple  in  its  mouth,  and  not  nursing,  for  more  than  one  or 
two  minutes. 

After  removing  the  infant  from  the  breast,  the  nipples  should  be 


BREAST-FEEDING         '  161 

cleansed  with  water  or  boracic  acid  solution.  Alcohol  and  water,  equal 
parts,  may  be  applied  if  there  is  any  tendency  to  inflammation;  if 
any  fissures  are  present,  a  2  per  cent,  nitrate  of  silver  solution  should  be 
painted  over  the  cracks,  and  the  baby  should  nurse  through  a  nipple 
shield. 

If  the  breast  becomes  inflamed,  nursing  should  be  discontinued,  and 
an  ice-bag  or  a  number  of  thicknesses  of  gauze  wet  in  a  satiu-ated 
solution  of  magnesium  sulphate  should  be  applied  over  the  inflamed 
surface.  The  breast  should  be  well  bandaged,  the  mother  kept  at  rest 
and  given  a  laxative.  If  the  breast  becomes  filled  with  milk,  a  sufficient 
amount  may  be  pumped  out  to  relieve  the  tension  and  pain. 

Human  Milk. — Colostrum  appears  in  the  breasts  at  about  the  fourth 
month  of  pregnancy,  and  a  few  drops  can  usually  be  expressed  from  the 
breasts  at  this  early  period.  The  amount  of  colostrum  gradually 
increases  as  pregnancy  advances,  and  persists  until  the  flow  of  milk  is 
established,  which  usually  occurs  about  three  or  fom-  days  after  the 
baby  is  born. 

Colostrum  is  yellow  in  color  due  to  the  colostrum  corpuscles,  less 
sweet  than  human  milk,  more  distinctly  alkaline  in  reaction,  and  the 
specific  gravity  is  higher — 1.036  to  1.040.  It  forms  large  coagula 
upon  heating  and  may  even  coagulate  upon  standing.  It  contains 
a  high  percentage  of  protein  and  .3.34  per  cent,  of  fat.  The  fat  glob- 
ules vary  in  size,  and  colostrum  corpuscles  are  present. 

These  colostrum  corpuscles  consist  of  large  cells  filled  with  fat 
globules  of  varying  size  and  containing  a  large  nucleus,  and  are  four 
or  five  times  as  large  as  the  milk  globules. 

The  composition  of  colostrum,  according  to  Camerer  and  Soldner  is: 

Water 86.70 

Proteids 3.07 

Fat 3.34 

Milk  sugar " 5 .  27 

Ash 0.40 

The  colostrum  corpuscles  gradually  disappear  from  the  milk,  and 
usually  are  not  found  after  the  twelfth  or  thhteenth  day  following 
delivery. 

Advantages  of  Breast-feeding. — It  is  impossible  to  place  too  much 
emphasis  upon  the  statement  that  breast  milk  is  the  best  food  for 
an  infant.  It  is  a  well  established  fact  that  the  milk  of  each  mammal 
is  especially  adapted  not  only  to  supply  the  demands  of  nutrition  for 
the  growing  body  of  its  young,  but  also  to  develop  the  digestive 
apparatus.  If,  then,  an  infant  is  nursed  by  its  mother,  its  digestive 
apparatus  develops  normally,  and  gradually  builds  itself  up  to  the 
point  where  it  can  digest  other  foods  than  milk. 

Unfortunately,  among  the  wealthier  classes,  many  mothers  are 
unable  to  nurse  their  babies  for  the  entire  period  that  is  usually  con- 
sidered advisable — ten  or  twelve  months — and  it  is  also  not  uncommon 
to  find  among  the  working  class  women  who  are  so  poor  that  they  have 
11 


162  INFANT  FEEDING 

to  leave  their  babies  at  home  or  in  a  Day  Nursery,  and  go  out  to  work; 
or,  but  this  is  less  common — those  who  are  unable  to  nurse  their  babies 
because  of  poor  food,  overwork,  and  bad  hygienic  surroundings. 

However,  the  large  majority  of  American  women  are  between  these 
two  extremes,  and  many  of  them  are  able,  and  almost  all  of  them  can 
be  persuaded  to  try,  to  nurse  their  babies.  A  very  brief  study  of  the 
chapter  on  Infant  ^Mortality  will  show  that  almost  all  the  deaths 
occur  in  bottle-fed  babies.  During  the  famous  siege  of  Paris,  the 
mortality  among  infants  actually  decreased  because  the  women,  in 
spite  of  all  the  privations  and  hardships  which  they  were  compelled 
to  undergo,  had  to  remain  at  home  and  nurse  their  babies. 

It  is  a  mistake  to  wean  an  infant  simply  because  it  is  not  gaining  in 
weight  a  sufficient  number  of  ounces  each  week,  or  because  it  vomits 
occasionally,  has  abdominal  pain,  or  the  stools  are  not  normal  in  color 
or  consistency.  It  is  possibly  true  that  the  breast  milk  this  child  is 
receiving  is  not  an  ideal  food,  but  the  correct  treatment  is  not  to  wean 
the  baby  but  to  go  carefully  over  all  the  facts  connected  with  its 
feeding;  see  if  the  mother  is  worried  by  household  or  other  c^res, 
regulate  her  food,  sleep  and  exercise;  give  her,  if  she  requires  them, 
appropriate  tonics. 

Investigate  the  daily  life  of  the  infant  with  the  same  care — is  it 
being  fed  regularly;  are  its  bathing,  clothing,  sleep,  and  outdoor  life  all 
that  is  to  be  desired ;  can  any  medicine  be  given  that  might  assist  its 
digestion?  Our  efforts  then  would  be  directed  not  only  to  improving 
the  quality  and  increasing  the  quantity  of  the  milk  by  building  up  the 
mother,  but  also  to  place  the  child  under  those  conditions  which  would 
tend  to  improve  its  digestion. 

If  it  still  failed  to  gain  and  the  quantity  of  the  milk  was  deficient, 
a  small  supply  of  properly  prepared  cow's  milk  should  be  given  after 
each  breast-feeding.  This  method  of  giving  after  each  breast-feeding 
just  enough  properly  prepared  cow's  milk  to  compensate  for  the 
deficiency  of  the  breast  milk,  is  a  plan  that  is  applicable  to  a  very 
large  number  of  breast-fed  infants. 

If  the  supply  of  breast  milk,  as  is  frequently  the  case,  gradually 
becomes  less,  and  it  is  found  that  at  the  proper  hour  for  nursing  the 
breast  is  practically  empty,  an  entire  bottle  feeding  may  be  given  once 
or  oftener  during  the  day,  and  the  number  of  partial  breast  feedings 
be  reduced.  It  is,  however,  well  recognized  that  the  nursing  of  the 
infant  tends  to  keep  up  the  secretion  of  milk,  and  one  is  therefore 
reluctant  to  omit  entirely  any  more  breast  feedings  than  are  necessary. 

]\Iany  infants  are  weaned  because  a  chemical  analysis  of  the  mother's 
milk  shows  that  it  does  not  conform  to  the  accepted  standard  of  breast 
milk.  While  there  is  a  standard  for  breast  milk,  it  is  also  true  that 
this  standard  may  vary  normally  between  very  wide  limits,  that 
different  specimens  taken  from  the  same  mother  may  also  vary,  and 
that  the  milk  nursed  by  an  infant  may  vary  from  the  milk  drawn  from 
the  same  breast  with  a  pump. 

It  is  also  true  that  the  analvsis  varies  according  to  whether  it  is  the 


BREAST-FEEDING  163 

fore,  middle  or  end  of  a  nursing.  Moreover,  it  is  expensive  to  have 
an  analysis  of  breast  milk  made,  and  repeated  analyses  of  the  same 
milk  may  be  necessary  before  its  average  composition  is  determined. 
While  I  am  a  firm  believer  in  the  necessity  and  importance  of  breast 
milk  analysis,  I  still  wish  to  enter  a  protest  against  weaning  a  baby 
simply  because  the  analysis  shows  a  milk  that  does  not  conform  to 
the  accepted  standard. 

It  is  surely  unwise  to  wean  in  such  cases  until  every  effort  has  been 
made  to  improve  the  quality  and  increase  the  quantity  of  the  milk; 
we  must  remember  that  a  poor  breast  milk  is  often  better  than  a 
prepared  bottle,  and  that  breast  milk  contains  substances  that  are  of 
great  importance  to  the  infant,  and  of  great  protective  value. 

There  are  rare  cases  when  the  breast  milk  should  not  be  given, 
because,  in  spite  of  all  that  one  can  do,  the  baby  does  not  gain  in 
weight  and  does  have  constant  indigestion;  but  in  my  experience, 
they  are  very  rare  indeed. 

It  may  well  be  asked  "When  and  how  should  a  baby  be  weaned?" 
Having  decided  to  wean  the  baby,  it  is  always  safer  to  begin  giving  the 
cow's  milk  mixture  much  weaker  than  one  would  ordinarily  employ 
in  a  healthy  baby  of  the  same  age  who  had  been  fed  continuously  on 
the  bottle.  If  the  cow's  milk  mixture  is  started  at  about  one-half  the 
strength  usually  given  to  an  infant  of  the  age  of  the  one  being  weaned, 
it  may  be  gradually  and  cautiously  increased  if  it  is  evident  that  the 
infant  can  digest  it. 

If  an  infant  is  doing  well  on  the  breast,  it  is  not  wise  to  wean  it 
during  the  hot  summer  months  as  the  change  from  breast  to  bottle 
is  quite  liable  to  be  associated  with  gastro-intestinal  disturbances  if 
the  child  is  in  a  locality  where  the  weather  is  very  warm.  Infants  who 
are  taken  to  a  climate  that  is  cool  in  summer  would  not  come  under 
this  rule. 

It  is  safer  to  wean  slowly  than  suddenly.  At  first  one  bottle-feed- 
ing each  day  may  be  given;  if  this  agrees  with  the  child,  in  two  or 
three  days  a  second  bottle-feeding  may  be  given.  By  this  plan  the 
breast-feeding  may  be  gradually  withdrawn  and  the  bottle  completely 
substituted. 

It  is  advisable  to  wean  the  baby  if  the  mother  has  any  disease  which 
she  may  transmit  to  her  child,  such  as  tuberculosis  or  typhoid  fever; 
or  if  the  mother  has  any  disease  which  the  strain  of  nursing  might 
aggravate,  as  acute  pneumonia,  tuberculosis  or  nephritis.  Pregnancy 
in  the  nursing  mother  requires  the  weaning  of  the  infant,  and  weaning 
may  be  done  gradually  if  desired.  If,  however,  the  prepared  milk 
given  the  baby  does  not  cause  any  intestinal  disturbance,  no  longer 
than  one  week  should  be  consumed  in  the  complete  weaning. 

If  the  illness  of  the  mother  is  of  a  minor  character,  and  of  such  a 
nature  that  it  will  not  be  transmitted  to  the  child,  nursing  at  the  breast 
may  be  continued  for  two  or  three  feedings  a  day  and  a  weak  milk 
mixture  given  for  the  other  feedings;  but  if  the  illness,  while  of  a  mild 
(ind  transient  character,   is  associated   with  severe  symptoms,   it   is 


164  INFANT  FEEDING 

often  safer  to  discontinue  nursing  entirely  for  a  few  days,  give  the  child 
a  weak,  modified  milk  mixture,  and  pump  the  breasts  several  times  a 
day  to  retain  the  milk.  INIenstruation  may  cause  temporary  gastro- 
intestinal disturbance  in  the  infant  and  perhaps  make  weaning  neces- 
sary for  several  days. 

A  wet-nurse  who  is  syphilitic  should  not  be  allowed  to  nurse  an 
infant,  and  an  infant  who  has  s^'philis  should  not  be  allowed  to  nurse 
from  a  wet-nurse.  In  the  first  instance,  the  M'^et-nurse  may  infect  the 
child,  and  in  the  second  case,  the  child  may  infect  the  wet-nurse.  If, 
however,  an  infant  is  suffering  with  inherited  syphilis,  it  may,  of 
course,  be  nursed  by  its  own  mother. 

Temporary  weaning  from  one  breast  is  necessary  if  the  mother  is 
suffering  from  a  mastitis  of  that  breast,  and,  if  the  inflammation  has 
been  severe,  nursing  must  be  resumed  cautiously. 

Weaning  depends,  in  the  large  majority  of  cases,  upon  the  ability 
of  the  mother  to  nurse  her  baby.  It  is  a  mistake  to  keep  an  infant 
entirely  on  the  breast,  if  the  amount  of  milk  secreted  is  insufficient  for 
the  nutritional  demands  of  the  infant.  Many  women  of  the  higher 
classes  are  unable  to  nurse  their  infants  entirely  for  more  than  a  few 
months,  and  partial  weaning,  when  the  milk  begins  to  fail,  is  necessary. 

Much  can  often  be  done  to  improve  the  quality  and  quantity  of 
breast  milk  by  building  up  the  general  health  of  the  mother,  giving 
her'  an  abundance  of  milk,  meat  and  eggs,  with  plenty  of  sleep  and 
avoidance  of  all  worry. 

In  other  cases,  when  the  baby  is  doing  fairly  well,  rather  than  make 
a  change,  nursing  is  prolonged  until  long  after  the  infant  is  a  year  old. 
Almost  all  infants  so  fed  become  anemic,  fail  to  develop  normally, 
and  rarely  show  a  continuous  and  normal  gain  in  weight.  If  a  child 
is  doing  well  on  the  breast,  it  is  wise  to  begin  giving  it  one  bottle  feeding 
a  day  when  it  is  nine  months  old.  The  one  bottle  of  prepared  cow's 
milk  is  of  advantage,  in  that  it  gradually  trains  the  digestive  organs 
of  the  infant  to  digest  cow's  milk;  it  also  makes  the  weaning  less 
abrupt. 

The  amount  of  food  being  received  by  the  infant  at  the  breast  is 
often  a  matter  of  importance  as  regards  weaning,  nutrition,  and  gastro- 
intestinal disorders.  Assuming  that  an  ounce  of  breast  milk  weighs 
one  ounce,  the  infant  may  be  weighed  before  and  after  feeding,  and  the 
difference  in  weight  represents  the  number  of  ounces  nursed.  From  a 
number  of  such  records  in  my  private  practice,  where  the  infants  were 
in  good  health  and  gaining  well,  the  following  table  is  compiled: 

7  days  old 10  to  16  ounces 

2  weeks  old 14  to  20       " 

2  to  4  weeks  old 18  to  24 

4  to  8  weeks  old 22  to  29 

2  to  3  months  old       .      .      .      .• 25  to  32 

3  to  4  months  old 26  to  35 

4  to  6  months  old 27  to  38       " 

6  to  9  months  old      .      , 30  to  41       " 


BREAST-FEEDING 


161; 


These  amounts  represent,  of  course,  only  a\'era,<i,es ;  tlie  lai'^ei-  the 
child,  the  greater  the  gastric  capacity  and  the  more  food  it  will  re(iuire. 
The  average  composition  of  breast  milk  according  to  Rotch  is: 


Reaction 


Water 

Mineral  matter 
Total  solids 

Fats.      .      .       . 


Milk  sugar 
Proteins 
Caseinogen 
Whey  proteins 
Coagulable  proteins 
Coagulation  of  proteins 
acids  and  salts    . 


by 


Coagulation  of  proteins  by 

rennet 

Action  of  gastric  juice 


Woman's  milk  directly  from 
the  breast. 

Amphoteric  (more  alka- 
line than  acid) 

87  to  88  per  cent.    ^ 

0.2  per  cent. 

12  to  13  per  cent. 

4  per  cent,  (relatively  poor 
in  volatile  glycerides) 

7  per  cent. 

1.5  per  cent. 

^  to  I  of  the  total  proteins 

I  to  I  of  the  total  proteins 

Small  proportionately 

With  greater  difficulty; 
curds  small  and  floccu- 
lent 

Does  not  coagulate  readily 
Proteins  precipitated  but 
easily  dissolved  in  excess 
of  the  gastric  juice 


Cow's  milk  freshly  milked. 
Amphoteric     (more     acid 

than  alkaline). 
86  to  87  per  cent. 
0.7  per  cent. 
13  to  14  per  cent. 
4  per  cent,  (relatively  rich 

in  volatile  glycerides). 
4.75  per  cent. 
3.5  per  cent. 
2.66  per  cent. 
0.84  per  cent. 
Large  proportionately. 

With  less  difficulty ;  curds 
large  and  tenacious. 


Coagulates  readily. 
Proteins  precipitated  but 
dissolved  less  readily. 


The  following  table  from  Rotch  shows  the  composition  of  normal, 
poor,  over-rich  and  bad  milk: 


Normal  milk 

(healthy  life  as 

to  exercise  and 

food). 

Poor  milk 
(starvation) . 

Over-rich  milk 

(rich  feeding; 

lack  of  exercise). 

Bad  milk 
(pregnancy, 
disease,  etc.) 

Fat       ... 

.        4.00 

1.10 

5.10 

0.80 

Sugar  . 

7.00 

4.00 

7.50 

5.00 

Proteins     . 

1.50 

2.50 

3.50 

4.50 

Mineral  matter 

0.15 

0.09 

0.20 

0.09 

Total  solids     . 

.      12.65 

7.69 

16.30 

10.39 

Water        .      . 

.     87.35 

92.31 

83 .  70 

89.61 

100.00 


100.00 


100.00 


100.00 


Wet-nurse. — If  a  mother  is  unable  to  nurse  her  baby,  and  in  those 
rather  rare  cases  where  she  cannot  be  persuaded  to  nurse  her  infant, 
the  employment  of  a  wet  nurse  offers  the  best,  simplest  and  safest 
method  of  feeding  the  baby. 

There  are,  however,  certain  objectionable  features  connected  with 
wet-nursing  that  it  is  well  to  appreciate  at  the  outset.  The  class  of 
women  who  are  usually  available  is  generally  undesirable.  The  baby 
is  often  illegitimate,  and  the  nurse  worried  by  her  misfortune  and 
annoyed  by  the  father  of  her  child  and  her  so-called  friends.  The 
bringing  of  such  an  individual  into  a  household  is  not  usually  desirable. 
A  woman  of  a  quiet  and  phlegmatic  temperament  is  generally  to  be 
preferred,  as  nervousness  and  excitement  on  her  part  will  often  cause 
the  breast  milk  temporarily  to  disagree  with  the  infant. 


166  ,  INFANT  FEEDING 

It  is  nt)t  necessary  that  the  age  of  the  nurse's  child  shoiikl  correspond 
to  that  of  the  child  she  intends  to  nurse.  It  is  desirable  that  her 
baby  be  as  young  as  possible  if  it  is  proposed  to  have  her  continue 
nursing  for  any  considerable  number  of  months.  If  her  own  child  is 
seven  months  old  or  more,  the  probability  of  her  being  able  to  nurse 
for  more  than  three  or  four  months  is  not  great.  She  should  be  between 
twenty  and  thirty  years  of  age,  and  a  chemical  analysis  of  her  milk 
is  of  advantage  as  a  fair  index  of  its  quality. 

The  only  advantage  in  her  being  a  multipara  is  that  we  have  the 
history  of  a  previous  successful  ability  to  nurse  for  a  definite  number  of 
months.  She  should  be  free  from  syphilis  and  tuberculosis,  have  an 
even  temper,  and  live  as  normal  a  life  as  possible  as  regards  sleep, 
fresh  air,  and  exercise.    ■ 

Her  diet  should  consist  of  an  abundance,  but  not  an  excess,  of  plain 
food,  with  a  liberal  supply  of  cow's  milk,  about  one  quart  a  day. 
She  should  avoid  drinking  much  tea  or  coffee  and  all  alcoholic 
drinks  should  be  forbidden.  A  wet-nurse  who  must  have  ale  or 
beer  to  stimulate  her  secretion  of  milk  had  better  be  dispensed 
with. 

The  best  test  is  to  see  and  examine  carefully  her  own  baby.  If  it  is 
strong,  robust  and  well  developed,  one  may  be  reasonably  sure  of  her 
milk  being  of  good  quality  and  quantity.  In  Philadelphia,  it  is  usually 
possible,  by  applying  at  several  agencies,  to  secure  almost  immediately 
a  wet-nurse  with  a  negative  Wassermann. 

In  private  practice  among  the  class  of  patients  who  are  capable  of 
paying  for  the  services  of  a  wet-nurse,  it  is  almost  always  possible  to 
have  one's  directions,  as  to  bottle  feeding  and  general  care  and  manage- 
ment of  the  infant,  carried  out  in  compliance  with  the  orders  of  the 
attending  physician.  This  is  the  reason  why  wet-nursing  has  never 
been  popular  in  the  United  States;  still,  there  are  a  certain  number  of 
infants  who,  as  a  result  of  malnutrition  or  disease,  will  usually  do  better 
on  wet-nursing  than  on  the  bottle. 

Among  this  class  may  be  mentioned  especially  premature  or  delicate 
infants.  It  is  of  great  help  in  such  cases  to  be  able  to  secure  for  them  a 
plentiful  supply  of  good  breast  milk.  Young  infants,  convalescing 
from  an  acute  illness,  especially  of  the  gastro-intestinal  tract,  usually 
do  well  if  given  to  a  wet-nurse;  or  a  young  infant  who  has  been  badly 
fed;  and  has  failed  to  gain  in  weight  for  some  weeks,  will  usually  gain 
rapidly  if  given  a  sufficient  supply  of  breast  milk.  In  Philadelphia 
I  have  seen  the  mortality  in  a  certain  foundling  asylum  very  greatly 
reduced  by  boarding  out  the  infants  to  women  who  would  partly 
breast-feed  and  partly  bottle-feed  them.  The  feeding  and  care  the 
infant  receives  is  watched  systematically  by  a  competent  social 
worker,  and  a  member  of  a  board  of  women  managers. 

Alexins. — There  are  present  in  human  milk  substances  called  alexins, 
which  possess  bactericidal  and  globulicidal  properties.  They  are 
probably  partly  formed  in  the  breasts  and  partly  derived  from  the 
blood.    They,  undoubtedly,  tend  to  partially  protect  the  breast-fed 


PERCENTAGE   FEEDING  ]G7 

infant  from  infection  of  the  t>astro-intestinal  tract.  Breast  milk  also 
contains  other  protective  substances — agglutinins  and  antitoxins — and 
still  other  antibodies,  if  the  mother  is  immune,  may  be  present  in 
her  milk. 

PERCENTAGE  FEEDING. 

The  most  satisfactory  and  accurate  way  of  determining  the  com- 
position of  the  infant's  food  is  to  mix  it  according  to  percentages. 
It  is  not,  however,  a  method  of  feeding,  nor  does  it  determine  the 
ingredients  or  the  amount  of  the  various  food  elements  which  are 
suitable  in  the  individual  case.  These  factors  depend  upon  the  age, 
size,  and  health  of  the  infant,  and  upon  the  digestive  ability  of  its 
gastro-intestinal  tract. 

The  problem  is  how  to  change  or  modify  the  percentages  of  cow's 
milk  so  as  to  make  it  resemble  human  milk.  The  first  question  which 
naturally  suggests  itself  is,  why  one  should  feed  a  baby  on  different 
percentages  at  different  ages  when  the  percentages  of  breast  milk 
do  not  change  to  any  appreciable  degree  during  the  entire  period  of 
breast  feeding. 

The  answer  is  that  each  mammal  furnishes  a  milk  that  is  especially 
adapted  to  the  growth  and  development  of  the  digestive  organs  and 
body  of  its  young.  The  milk  of  the  cow  is  therefore  adapted  to 
the  growth  and  development  of  the  digestive  organs  and  body  of  the 
calf,  and  is  not  adapted  to  the  infant. 

The  young  infant  can  digest  cow's  milk  only  in  weak  mixtures, 
and  as  it  grows  older  and  stronger  can  digest  larger  quantities  and 
stronger  mixtures.  Cow's  milk  can  never  be  transformed  into  human 
milk;  but  we  can  modify  it  so  as  to  make  it  possible  for  an  infant  to 
live  and  grow  and  develop  upon  it. 

Percentage  feeding  offers  a  method  of  calculating  in  ounces  and 
drams  the  composition  of  a  given  formula  when  that  formula  is  written 
in  percentages;  or,  if  written  in  ounces  and  drams,  one  can  easily 
calculate  the  percentage  of  fat,  proteins,  and  sugar  that  it  contains. 

The  accuracy  of  such  a  mixture,  however,  depends  primarily  upon 
the  constant  composition  of  the  milk  and  cream  used.  In  the  labora- 
tory there  is  very  little  variation  in  the  composition  of  such  a  formula; 
but,  in  the  home,  modification  of  the  milk  is  necessarily  not  so  accu- 
rate. The  errors  which  occur,  however,  are  in  the  actual  percentages, 
the  proportions  of  the  various  food  elements  being  little  altered,  con- 
sequently most  infants  are  able  to  compensate  for  these  errors,  and  the 
slight  variations  in  the  composition  of  the  food  are  not  noticeable. 
Fats,  carbohydrates,  and  proteins  are  the  elements  that  especially 
concern  us  in  the  modification  of  cow's  milk,  the  salts  being  of  less 
practical  importance,  hence  the  percentage  formula  states  only  what 
percentage  of  these  three  elements  should  be  used. 

Modification  of  Milk. — ^Modifying  milk  is  the  process  of  diluting  it 
and  adding  to  it  in  such  manner  that  the  fats,  proteins,  and  carbo- 


168  IXFAXT  FEEDING 

hydrates  are  combined  in  the  proper  proportions  to  make  them 
assimilable  and  properly  to  nom-ish  the  child.  Because  of  the  difference 
in  the  composition  of  cow's  milk  and  human  milk,  modification  is 
always  necessary  when  cow's  milk  is  fed  to  the  young  infant;  for, 
while  the  percentage  of  fat  is  nearly  the  same,  the  percentage  of  sugar 
is  lower  in  cow's  milk,  and  the  percentage  of  proteins  higher. 

The  old  method  of  infant  feeding,  which  was  simple  dilution  while 
decreasmg  the  amount  of  proteins  to  normal,  caused  such  a  decrease 
in  the  amount  of  fat  and  carbohydrates  that  it  did  not  meet  the 
indications  of  modified  milk.  In  order  to  make  the  mixture  prepared 
from  cow's  milk  correspond  to  the  general  relation  of  fat,  sugar,  and 
proteins  in  human  milk,  it  is  necessary  to  use  cream  in  the  feeding 
mixture  so  that  the  dilution  which  reduces  the  amount  of  proteins 
will  not  cause  too  great  a  diminution  in  the  amount  of  fats;  for  w^hen 
cream  forms  there  is  an  unequal  division  of  fats  in  the  upper  and  lower 
contents  of  a  receptacle,  but  the  proportion  of  sugar  and  proteins  is 
practically  equal.  Thus,  simply  stated,  the  modification  of  milk 
consists  in  the  dilution  of  cream  with  water  and  the  addition  of  milk 
sugar. 

The  protein  in  cow's  milk  is  4  per  cent.;  in  human  milk  1|  per  cent.; 
and  to  reduce  the  4  per  cent,  in  cow's  milk  to  the  required  percentage 
in  human  milk,  it  is  necessary  to  add  a  diluent,  and  the  one  commonly 
used  is  water.  This  addition  of  water,  however,  also  reduces  the 
percentage  of  fat;  in  fact,  usually  reduces  it  to  a  point  lower  than  the 
percentage  desired  in  the  modified  milk  mixture.  Now,  to  increase  this 
percentage  of  fat  it  is  necessary  to  add  to  our  mixture  something  that 
contains  a  relatively  high  percentage  of  fat  and  a  low  percentage  of 
protein,  therefore  we  add  cream.  Cream,  containing  as  it  does  a 
high  percentage  of  fat,  can  easily  be  reduced  by  the  addition  of  water 
so  as  to  contain  any  desired  percentage.  But,  as  this  addition  of  water 
also  reduces  the  percentage  of  protein  in  the  cream,  it  is  often  necessary 
to  add  to  the  mixture  an  ingredient  that  contains  a  low  percentage  of 
fat  and  a  high  percentage  of  protein.  This  is  well  supplied  by  fat- 
free  milk,  which  contains  4  per  cent,  of  protein  and  practically  no  fat. 
Cow's  milk  contains  4  per  cent,  of  milk  sugar,  human  milk  7  per  cent., 
and  our  addition  of  water  still  further  reduces  the  sugar  percentage. 
To  bring  the  sugar  percentage  in  oiu"  modified  milk  up  to  the  desired 
amount,  we  simply  add  milk  sugar.  The  modification  of  milk  is  thus 
briefly  as  follows: 

We  add  water  to  cow's  milk  to  dilute  its  4  per  cent,  of  protein;  we 
add  cream  which  is  rich  in  fat  to  bring  up  the  fat  to  the  percentage 
desired;  and  we  add  milk  sugar  to  raise  the  percentage  of  sugar  to 
that  required  by  the  infant,  usually  6  or  7  per  cent.  jNIodified  milk 
mixtures  may  be  made  with  cream,  whole  milk,  water,  and  milk  sugar; 
or,  instead  of  the  whole  milk,  fat-free  milk  may  be  used.  The  latter 
method  is,  I  believe,  the  better  for  home  modification,  therefore,  will 
be  the  one  followed.  It  is  easy  to  understand,  and  the  modifications 
are  quickly  made  at  home. 


PERCENTAGE  FEEDING  169 

In  order  that  the  mochficatioii  of  milk  at  home  ma\',  as  nearly  as 
possible,  approach  the  exactness  of  the  laboratory,  it  is  necessary  that 
the  family  be  supplied  with  milk  and  cream  of  definite  percentages. 
This  milk  or  cream  may  be  procured  in  Philadelphia  from  those  dairies 
recommended  by  the  Milk  Commission  of  the  Philadelphia  Pediatric 
Society.  All  bottles  and  nipples  should  be  carefully  sterilized.  The 
arms  and  forearms  of  the  person  selected  as  modifier  should  be 
thoroughly  cleansed  and  she  should  have  the  following  for  her  modi- 
fications:, milk  and  cream  of  known  percentages,  sterile  water,  lime- 
water,  milk  sugar,  a  cream  dipper,  milk  sugar  measures  holding  3f 
drams,  an  8  ounce  graduate,  a  large  spoon  sterilized.  Gravity  cream  is 
often  used,  and  can  be  obtained  as  follows:  if  the  milk  is  allowed  to 
stand  in  the  ordinary  quart  jar  for  eight  hours,  the  top  4  ounces 
represent  a  20  per  cent,  fat  cream,  the  top  6  ounces  a  16  per  cent,  fat 
cream,  and  the  top  8  ounces,  a  12  per  cent,  fat  cream.  Gravity  cream 
contains  more  bacteria  than  does  separator  cream,  but  the  centrifuge, 
it  is  claimed  by  some,  does  injury  to  the  emulsion  of  the  fat.  Personally, 
I  have  obtained  equally  good  results  from  both  creams. 

It  must  be  remembered  that  accuracy  is  the  keynote  to  a  home 
modification,  and  it  is  best  that  all  directions  to  the  mother  or  nurse 
be  carefully  written  out  in  ounces  of  cream,  milk,  water,  lime-water, 
and  measures  of  sugar  of  milk.  The  physician  should  learn  to  think 
in  percentages,  and,  having  decided  upon  the  percentages  to  be  used, 
be  guided  by  the  child's  age,  development,  weight,  digestion,  and, 
if  indigestion  be  present,  also  influenced  by  the  fact  whether  it  is  the 
fat,  protein,  or  sugar  which  is  the  cause  of  the  indigestion.  After  taking 
these  factors  into  consideration,  he  should  decide  upon  the  exact  per- 
centage of  fat,  sugar  and  protein  to  be  used,  and,  by  reference  to  his 
pocket  memoranda,  transfer  this  into  ounces  for  the  benefit  of  the 
mother  or  nurse. 

A  convenient  and  easily  understood  form  of  home  modification 
is  as  follows :  from  a  quart  of  milk,  which  has  been  bottled  eight  hoiu-s, 
remove  the  top  8  ounces;  count  this  as  12  per  cent,  fat  cream.  Count 
as  fat-free  milk,  the  lowest  8  ounces  of  the  quart.  Using  this  12  per 
cent,  fat  cream  and  the  fat-free  milk,  the  following  percentages  can  be 
obtained,  covering  fairly  well  the  different  combinations  of  fat,  pro- 
tein and  sugar  desired.  One  quart  of  milk  is  enough  by  this  method 
until  the  baby  is  about  three  months  old. 


FIRST  WEEK. 

Fat 2.00 

Sugar .       5.00 

Proteins     .      . 0.75 

12  per  cent,  cream.     Fat-free  milk. 

Cream 3j^  ounces 

Milk Ij^  ounces 

Lime-water 1      ounce 

Water .      .      .      q.  s.  20      ounces 

Milk  sugar 2  ,    measures 


170  INFANT  FEEDING 

SECOND  WP:EK. 

FaL 2.00 

Sugar 6.00 

Protein 1.00 

Cream , S}4  ounces 

Milk 2}4  ounces 

Lime-water 1      ounce 

Water q.  s.    20      ounces 

Milk  sugar 2}/^  measures 

THIRD   WEEK. 

Fat 2.50 

Sugar 6.00 

Proteins 1.00 

Cream 4J4  ounces 

Milk 1%:  ounces 

Lime-water 1      ounce 

Water        q.  s.    20      ounces 

Milk  sugar 2}4  measures 

FOUR   TO   SIX   WEEKS. 

Fat 3.00 

Sugar 6.50 

Proteins 1.50 

Cream 5      ounces 

Milk S}/2  ounces 

Lime-water 1      ounce 

Water q.  s.    20      ounces 

Milk  sugar 2}4  measures 

SIX   TO   TWELVE   WEEKS. 

Fat 3.50 

Sugar 6.50 

Proteins 1.50 

Cream o%  ounces 

Milk S}4  ounces 

Lime-water ^ ....       1      ounce 

Water q.  s.    20      ounces 

Milk  sugar 2}4  measures 

THREE   TO   FOUR   MONTHS. 

Fat 4.00 

Sugar 7.00 

Proteins 1.50 

Cream 6^  ounces 

Milk 2}4:  ounces 

Lime-water 1      ounce 

Water q.  s.    20      ounces 

Milk  sugar 2^/^  measures 

FOUR    TO    EIGHT    MONTHS. 

Fat 4.00 

Sugar 7.00 

Proteins .        2.00 

Cream 6^  ounces 

Milk 4^  ounces 

Lime-water 1      ounce 

Water q.  s.    20      ounces 

Milk  sugar 234  measures 

EIGHT   TO   NINE    MONTHS. 

Fat 4.00 

Sugar 7.00 

Proteins 2.50 

Cream 6%  ounces 

Milk 7}4  ounces 

Lime-water 1      ounce 

Water q.  s.    20      ounces 

Milk  sugar 2      measures 


PERCENTAGE   FEEDING 


171 


NINE   TO   TEN    MONTHS. 

Fut -iUO 

Sugar 7.00 

Proteins 3.00 

Cream  6^  ounces 

Milk 10>2  ounces 

Lime-water     . 1      ounce 

Water q.  s.    20      ounces 

Milk  sugar l3^  measures 

TEN    TO    TWELVE    MONTHS. 

Fat 4.00 

Sugar 5.00 

Proteins 3.50 

Cream ■ 6^  ounces 

Milk 11%  ounces 

Lime-water 1      ounce 

Water q.  s.    20      ounces 

Milk  sugar 3^  measure 

AFTER  TWELVE  MONTHS. 
Unmodified  cow's  milk. 

In  order  to  obtain  certain  low  protein  percentages  with  certain  fat 
percentages,  it  is  necessary,  instead  of  removing  the  top  eight  ounces 
and  using  a  12  per  cent,  fat  cream,  to  remove  the  top  six  ounces  for  a 
16  per  cent,  fat  cream,  or  the  top  four  ounces  for  a  20  per  cent,  fat 
cream.  The  following  table  designed  by  Dr.  Maynard  Ladd,  makes 
this  a  calculation  of  a  few  moments  only. 


20- 

ounce  mixtures. 

Ounces  of  ere 

Ounces  fat-free  milk 

£ 

I'ercentage  of 

used  with  creams  of 

■  .2 

P 

:3 

^     i    ^    '     ^ 

s 

c 

a         a 

a    I    a    \     a 

a 

c 

gS 

No. 

c 

S 

.  0         0 

0        ;           U 

0 

0 

S               3 

^ 

M 

-8 

ft 

ft          D. 

a 

a        a 

a 

a 

a 

3 

o 

N      1      33 

0 

0              <M 

CD 

0 

fe 

03 

PL, 

< 

1 

<N 

1 

1.50 

4.50 

0.25 

5 

1 

m 

.  .    i 

2 

2 

1.50 

4.50 

0.50 

5 

3 

2Hi  2 

1V9. 

^2 

1 

13/2 

2 

3 

2.00 

5.00 

0.25 

5 

2 

234 

4 

2.00 

5.00 

0.50 

5 

314 

2V?. 

2    . .  1  . . 

v?. 

1 

2K 

5 

2.00 

5.00 

0.75 

5 

4 

314 

2K2 

2    i    Hi    lYi 

2H 

234 

2 

6 

2.00 

5.50 

1.00 

5 

4 

3^1  2M 

2   !  i3/4i    23^ 

3M 

34 

1     .   2M 

7 

2.50 

5.00 

0.50 

5 

..  ;3M 

2Hi  ••  :  .. 

H 

1           2H 

8 

2.50 

5.50 

0.75 

5 

.:i4Ml  314 

23^  ..  '     ^ 

134 

2 

1      24 

9 

2.50 

6.00 

1.00 

5 

5  i  4141  3H 

2M    1          IM 

24 

23/2 

1     23^ 

10 

3.00 

6.00 

0.50  1  5 

.  .  1    .  .    1  3M 

3         .  .        .  . 

% 

1           2M 

11 

3.00 

6.00 

0.75     5 

.  .  1  5     1  3% 

3     :    ..    '     .. 

IK 

2 

2^2 

12 

3.00 

6.00 

1.00  !  5 

6      5      :  3% 

3 

1 

234 

3 

2M 

13 

3.00 

6.00 

1.25  1  5 

6     5        3% 

3  1  \y^ 

214 

31/^ 

4K 

234 

14 

3.00 

6.50 

1.50     5 

6     5        3% 

3        2K 

33/2 

434 

5^2 

2K 

15 

3.00 

6.50 

2.00      5 

6:5        3% 

3       53^ 

63/2 

734 

8^/^ 

2 

16 

3.50 

6.00 

0.50      5 

3K    .. 

1           2^ 

17 

3.50 

6.00 

0.75  ■  5 

■■  :  ■■  ,43^ 

3K!-..  i  .. 

1 

1           2H 

18 

3.50 

6.50 

1.00  1  5 

..    5% 

^y? 

33^ 

.  .■  j    .  . 

IK 

234 

1     !    23^ 

19 

3.50 

6.50 

1.25  1  5 

7     53^ 

4^ 

33/2 

3^i    1% 

3 

4            1           23^ 

20 

3.50 

6. 50 

1.50     5 

7  1  5M 

4J^ 

3^'  2     !     31^ 

4^2 

53^1       1 

24 

21 

4.00 

6.00 

0.60     5 

.  .  !   . .   1  . . 

4         .  . 

.  .     1       1 

23/2 

22 

4.00 

6.00 

0.75 

5 

5 

4 

1   !    1 

2^/2 

23 

4.00 

7.00 

1.00 

5 

5 

4         .. 

1 

2 

1    :  24 

24 

4.00 

7.00 

1.25 

5 

634 

5 

4        .  . 

4 

21/^ 

33^ 

1      23^ 

25 

4.00 

7.00 

1.50  :  5 

8 

634 

5 

4        1 

23^ 

4 

5  i    1    ;  23^ 

26 

4.00 

7.00 

2.00      5 

8  i  6^'  5 

4        31^'     43^ 

63^ 

73^    1      24 

27 

4.00 

7.00 

2.50  :  5 

8   :   63/4,   5 

4        64:     73^ 

934 

loK     1,2 

28 

4.00 

7.00 

3.00  1  5 

8  1  6%   5 

4      934:  lOK 

1234 

134    1    !   13^ 

29 

4.00 

6.00 

3.00  i  5 

8  !  6%   5 

4        94i  103^ 

1234 

134    1       1 

30 

4.00 

5.50 

3.00     5 

8     6M   5 

4       94    103^ 

12M 

134     1         4 

172  INFANT  FEEDING 

This,  liowever,  will  only  I'esiilt  in  making  the  jK-rcentagcs  of  the 
different  food  elements  the  same  as  in  liuman  milk;  for,  no.  matter 
how  cow's  milk  is  modified,  it  will  still  differ  from  human  milk  because 
the  composition  of  the  fat  is  different,  the  ferments  are  not  the  same, 
and  the  specific  serum  reaction  remains  unchanged. 

The  method  devised  by  Rotch  is,  perhaps,  the  most  popular  one  for 
infant  feeding.  It  is  based  upon  the  principle  that  we  cannot  feed  all 
infants  on  the  same  mixture,  and  that  each  infant  should  be  considered 
as  a  distinct  problem  in  constructing  a  formula.  The  mixtures  are 
made  from  cream,  skimmed  milk,  milk  sugar,  and  lime-water,  and  the 
diluent  generally  used  is  water.  The  constituents  of  the  milk  can  be 
rearranged  by  this  method  so  that  any  desired  formula  can  be  produced, 
and  such  mixtures  are  usually  prescribed  in  percentage  form;  that  is, 
fats,  2.5  per  cent. ;  carbohydrates,  5  per  cent. ;  proteins,  0.75  per  cent. 

If  a  given  formula  does  not  agree  with  an  infant,  it  is  easy  to  reduce 
or  increase  any  of  the  food  elements  by  decreasing  or  increasing  the 
percentages  in  the  mixture.  The  best  method  is  for  the  physician  to 
think  in  percentages.  iVfter  deciding  just  what  percentage  of  fats, 
protein,  and  sugar  the  infant  or  child  may  require,  he  should  write  a 
prescription  for  these  percentages,  the  number  of  feedings  necessary 
in  twenty-four  hours,  the  amount  in  ounces  and  drams  of  each  feeding, 
the  degree  of  alkalinity,  and  the  degree  of  heating  which  the  feedings 
may  require.  This  is  sent  to  a  laboratory,  and  each  day  the  bottles 
of  milk  are  prepared  according  to  his  prescription,  and  are  left  packed 
in  ice  at  the  home  of  the  patient. 

If  a  milk  laboratory  is  not  located  near  the  residence  of  the  child, 
or  if  the  expense  of  laboratory  feeding  is  too  great,  the  milk  may  be 
modified  at  home.  This  home  modification  is  not  difficult.  The  phy- 
sician must  write  out  his  directions  carefully  and  in  detail,  and  anj' 
one  of  ordinary  intelligence  is  capable  of  carrying  them  out.  In  fact, 
home  modification  has  practically  largely  displaced  laboratory  feeding. 
A  family  that  can  afford  to  feed  a  child  by  the  laboratory  method 
usually  has  a  child's  nurse  who  is  quite  competent  to  do  home  modifi- 
cation. 

Calculation  of  Percentages. — Given  a  milk  or  cream  containing  a 
standard  amount  of  the  various  food  elements,  the  calculation  of  a 
percentage  formula  is  easily  made  by  employing  the  following  method : 

Percentage  desired  X  quantity  desired 
DiAdded  by  the  standard  per  cent. 

By  means  of  this  formula  the  amount  of  fat  and  proteins  is  deter- 
mined; for  example,  20  ounces  of  a  3  per  cent,  fat  and  2  per  cent, 
protein  mixture  is  desired,  for  which  a  12  per  cent,  fat  cream  is  used. 
In  order  to  determine  the  proper  amount  of  this  12  per  cent,  cream 
to  use,  the  desired  percentage  (3)  is  multiplied  by  the  desired  number 
of  ounces  (20)  and  divided  by  the  standard  percentage  (12)  which 
gives  us  5  ounces  of  cream. 

Standard  per  cent.  3  X  desired  quantity  20 

=  5 

Standard  per  cent.  12 


PERCENTAGE  FEEDING  173 

In  order  to  determine  the  proper  amount  of  milk  or  cream  which  this 
20-oimce  mixture  must  contain  to  give  it  a  2  per  cent,  protein  content, 
the  desired  percentage  (2)  must  be  muhiphed  by  the  number  of  ounces 
desired  (20),  and  this  divided  by  the  standard  percentage  (3^),  which 
gives  approxim.ately  11|  ounces  as  the  result. 

Inasmuch  as  the  cream  added  to  give  the  desired  percentage  of 
fat  to  the  mixture  does  not  contain  enough  proteins  to  furnish  the 
desired  percentage  of  proteins,  the  difference  is  made  up  by  adding 
skimmed  milk  which  raises  the  protein  content  without  influencing 
the  fat  content.  This  particular  formula  requires  only  5  ounces  of 
cream  to  furnish  the  necessary -percentage  of  fats,  whereas  \1\  ounces 
of  milk  or  cream  are  necessary  to  provide  the  proper  amount  of  pro- 
teins; therefore,  the  difference  between  5  ounces  and  11|  ounces,  or 
6^  ounces,  of  fat- free  milk  m.ust  be  added. 

The  amount  of  sugar  in  percentage  formulas  is  determined  by 
estimating  the  amount  of  sugar  needed  in  the  mixture,  subtracting 
the  amount  of  sugar  in  the  milk  and  cream  utilized  to  supply  the 
desired  amount  of  fats  and  proteins  for  that  particular  mixture,  and 
supplying  the  difference  b}^  adding  milk  sugar.  Thus,  if  6  per  cent, 
carbohydrates  is  desired  in  the  above  formula,  6  per  cent,  of  20  ounces, 
or  1.2  ounces,  will  be  required. 

Five  ounces  of  cream  are  used  to  furnish  the  fats  and  proteins,  and 
this  contains  4  per  cent,  carbohydrates  or  0.2  ounce;  therefore  0.2 
ounce,  or  the  amount  of  carbohydrates  already  contained  in  the 
formula,  is  subtracted  from  1.2  ounces,  the  total  amount  of  carbo- 
hydrates required,  leaving  1  ounce  of  carbohydrates  to  be  supplied. 

Five  per  cent,  of  lime  water  is  usually  added  to  these  mixtures,  and 
then  enough  of  boiled  water  to  make  20  ounces.  This  formula  would 
read  as  follows: 

I^ — 12  per  cent,  fat  cream 5  ounces 

Fat-free  milk none 

Sugar  of  milk 1  ounce 

Lime-water 1        " 

Boiled  water q.  s.  ad.  20  ounces 

Amount  of  Cream  in  Milk. — Cream  is  technically  any  milk  which 
contains  over  4  per  cent,  of  fat.  When  milk  is  allowed  to  stand,  the 
cream  which  forms  at  the  top  of  the  receptacle  varies  in  its  fat  content, 
that  at  the  top  being  much  richer,  and  the  cream  below  it  thinner  at 
different  depths,  until  skimmed  milk  or  fat-free  milk  is  reached.  The 
following  diagram  shows  approximately  the  percentages  of  cream  to 
be  found  at  different  levels  in  a  quart  bottle  of  a  4  per  cent,  fat  milk 
which  has  been  allowed  to  stand  for  six  to  twelve  hours  (Fig.  25). 

Albumin  Milk:  Eiweissmilch :  Protein  Milk. — Albumin  milk  is  a 
preparation  containing  a  high  percentage  of  protein  (3  per  cent.), 
very  little  sugar  (1.5  per  cent.),  and  2.5  per  cent,  of  fat.  It  has  been 
dev'eloped  "on  the  theory  that  sugar  is  the  main  cause  of  intestinal 
fermentation,  and  that  fermentation  of  the  sugar  depends  on  the 


174 


INFANT  FEEDING 


-125; 


-105;. 


/ 


concentration  of  the  whey  and  the  relative. proportions  of  casein  and 
sugar  in  the  mixtures.  A  diminution  of  the  salts  is  effected  by  dilution 
of  the  whey. 

Albumin  milk  is  claimed  by  Finkelstein  and  Meyer  to  be  beneficial 
in  all  disturbances  of  nutrition  which  are  accompanied  by  diarrhea, 

and  may  also  be  given  to  the  well  infant 
from  birth.  Albumin  milk  is  prepared  by 
heating  one  quart  of  whole  milk  to  100° 
F.,  and  adding  4  teaspoonfuls  of  essence 
of  pepsin,  which  is  thoroughly  stirred  in, 
and  the  mixture  is  then  allowed  to  stand 
at  100°  F.  until  a  curd  has  formed.  The 
whey  is  then  separated  from  the  curd  by 
straining  through  a  linen  cloth,  and  is  dis- 
carded, and  the  curd  is  pressed  through  a 
fine  sieve  two  or  three  times  by  means  of  a 
wooden  mallet  or  spoon,  one  pint  of  water 
being  added  during  this  process. 

The  precipitate  should  now  be  very  finely 

divided,  and  the  mixture  should  look  like 

milk.    One  pint  of  buttermilk  is  now  added. 

Buttermilk   contains   very  little   sugar    of 

milk,  and  its  lactic  acid  content  is  of  benefit. 

One  quart  of  albumin  milk  contains  about 

380  calories,  so  that  it  is  necessary  to  increase 

the   caloric  value   of   this   food  by  giving 

some   additional   nourishment   as    soon  as 

improvement  is  noted. 

It  can  readily  be  seen  that  the  preparation  of  albumin  milk  may 

prove  quite  a  difficult  task  in  the  home,  and  this  to  a  great  extent 

limits  its  general  application.     But  the  principles  of  albumin  milk 

feeding  may  be  carried  out  in  the  home  by  the  addition  of  powdered 

^  casein  and  paracasein  to  ordinary  milk  mixtures. 

Buttermilk. — Buttermilk  has  long  been  used  in  the  feeding  of 
infants,  and  good  results  are  usually  obtained,  because  it  contains  a  low 
percentage  of  sugar,  3  to  4  per  cent.,  a  low  fat  content,  |  to  1  per  cent., 
and  a  high  protein  content,  2  to  3  per  cent.;  this  is  the  old-fashioned 
buttermilk  which  was  made  from  sweet  milk  as  a  by-product  in  the 
manufacture  of  butter. 

It  can  be  made  at  home  by  thoroughly  mixing  a  quart  of  fresh 
milk,  a  pint  of  water,  a  pinch  of  salt,  and  one  lactic  acid  bacilli  tablet, 
and  allowing  this  mixture  to  stand  in  a  covered  receptacle  at  room 
temperature  for  from  eighteen  to  twenty-four  hours,  when  it  may  be 
placed  on  ice  until  used.  But  since  it  can  be  procured  from  any  milk 
dealer,  it  is  needless  to  make  it  at  home  except  in  localities  where 
it  is  unobtainable. 

Buttermilk  contains  from  0.5  to  0.7  per  cent,  of  lactic  acid,  and  the 
lactic  acid  bacilli  are  alive  and  active  in  it,  imless  they  have  been 


i',^ 


Fig.  24. 


PERCENTAGE  FEEDING  175 

destroyed  by  heating.    It  contains  more  whey  protein  than  fresh  milk, 
and  the  casein  it  contains  is  very  finely  divided,  so  that  it  is  most 
/'  advantageous  in  those  cases  which  require  a  low  fat  and  high  protein^ 
content  in  easily  assimilable  form. 

Buttermilk  is  very  rarely  given  plain,  however,  but  is  usually  mixed 
'  with  wheat  flour  and  cane  sugar.  To  each  quart  of  buttermilk  two 
tablespoonfuls  of  cane  sugar  and  a  tablespoonful  of  wheat  flour  are 
added,  and  this  mixture  is  boiled  for  two  or  three  minutes  while  con- 
stantly stirred,  after  which  the  desired  feedings  are  bottled  and  placed 
on  ice  until  needed  for  use. 

The  action  of  the  lactic  acid  bacilli  is,  of  course,  lost  in  this  mixture, 
since  these  organisms  are  killed  by  the  boiling. 

Commercial  buttermilk  is  now  made  on  a  large  scale,  and  is  a  stabile 
product.  Much  time  and  thought  have  been  devoted  to  its  production, 
and,  as  made  by  the  Abbott  Dairy,  of  Philadelphia,  it  is  a  product 
which  has  a  constant  food  value,  and  can  be  used  with  confidence  in 
those  cases  where  buttermilk  is  indicated.    Their  process  is  as  follows: 

From  the  best  whole  milk,  2  per  cent,  of  the  fat  is  removed,  leaving 
a  milk  that  contains  fat  2  per  cent.,  sugar  4  per  cent.,  protein  3.5  to 
4  per  cent.  This  milk  is  heated  to  180°  F.,  and  kept  at  this  temperature 
for  thirty  minutes.  The  milk  is  then  rapidly  cooled,  and  when  it  has 
been  reduced  to  76°  F.  a  starter  is  added,  and  during  the  following 
twelve  hours  the  milk  is  kept,  as  nearly  as  possible,  at  75°  to  76°  F. 
It  is  then  churned  for  thirty  minutes,  being  cooled  during  the  process 
of  churning.  The  milk  is  now  bottled,  the  temperature  of  the  milk 
when  bottled  being  reduced  to  34°  F.  It  is  then  placed  in  the 
refrigerator  and  sold  to  the  consumer  the  next  day. 

The  starter  is  made  by  adding  lactic  acid  and  Bulgarian  bacilli  to 
sterilized  skimmed  milk.  The  total  solids  of  this  buttermilk  are  10 
per  cent.,  containing  2  per  cent,  fat,  4.25  per  cent,  sugar,  3  per  cent, 
protein,  and  0.75  per  cent,  of  lactic  acid. 

Whey. — Whey  is  an  opalescent  liquid  which  remains  after  the 
coagulation  of  casein.    Its  composition  is  as  follows: 

'  Protein 0.8  per  cent. 

Fat 0.2 

vSugar 4.7 

Lactic  acid 0.3 

Salts 0.6 

The  solid  portion  of  the  whey  of  cow's  milk  is  composed  of  lact- 

albumin,  lactprotein,  and  extractives.     Whey  is  made  by  adding  two 

teaspoonfuls  of  essence  of  pepsin  or  liquid  rennet  to  a  pint  of  luke- 

A^varm  skimmed  milk,  and  stirring  it  just  enough  to  mix  it  thoroughly. 

,it  is  then  allowed  to  stand  until  the  milk  separates  into  a  solid  and 

liquid  portion,  w^hen  the  curd  is  broken  up,  and  the  whole  preparation 

is  strained  through  several   thicknesses  of   cheesecloth.     The   whey 

passes  through  the  cloth,  but  it  contains  the  rennin  of  the  rennet  so 

that,  before  it  can  be  mixed  with  skimmed  milk,  whole  milk,  or  cream, 

the  rennin  must  be  destroyed  by  heating  the  whey  to  150°  F.,  and  then 

allowing  it  to  cool, 


176  INFANT  FEEDING 

Whey  is  given  to  infants  either  combined  with  a  cream  mixture  or 
alone.  When  combined  with  certain  percentages  of  cream,  we  have  a 
mixture  in  which  the  proteins  are  largely  lactalbumin  and  lactoglobulin, 
thus  resembling  the  protein  content  of  human  milk.  Whey,  alone,  is 
an  excellent  preparation  for  infants  suffering  with  gastro-intestinal 
disturbances  when  it  is  desirable  to  suspend  milk  temporarily;  it  is 
used  quite  often  in  infant  feeding. 

Proprietary  Foods. — Patent,  or  proprietary,  infant  foods  may  be 
divided  into  milk  modifiers  and  milk  foods,  those  in  the  first  group 
being  used  in  combination  with  milk,  those  of  the  second  being  intended 
as  a  perfect  food  which  does  not  require  the  addition  of  anything  but 
water.  These  foods  may  be  subdivided  according  to  their  ingredients 
as  follows: 

1.  Dried  milk,  to  which  completely  malted  cereals  have  been  added. 
Horlick's  Malted  "Slilk  and  Allenbury's  Food  are  examples  of  this 
group. 

2.  Dried  milk  in  combination  with  partially  malted  cereals,  as 
combined  in  Xestle's  Food  and  Carmick's  Food. 

3.  Completely  malted  cereals  which  contain  the  carbohydrates  in 
soluble  form  and  which  are  practically  a  desiccated  malted  extract. 
They  contain  a  very  small  amount  of  protein.  INIellin's  Food  is  a 
good  example  of  this  class. 

4.  Partially  malted  cereals,  such  as  Benger's  Food,  which  contains 
a  pancreatic  ferment  that  causes  the  conversion  of  starch;  and  Allen- 
biu-y's  Food,  No.  3,  Moore's  Food,  and  the  Savory  Foods.  Certain 
preparations  in  this  class,  such  as  Loeflund's  Malt  Soup,  are  not  only 
digestible,  but  when  combined  with  cow's  milk  may  prove  quite 
nourishing  for  a  limited  time. 

5.  This  group  includes  the  cereal  foods  in  Avhich  there  has  been 
little  or  no  conversion  of  starch,  and  includes  Robinson's  Patent 
Barley,  Ridge's  Food,  Neave's  Food,  and  Imperial  Granum. 

The  following  table,  furnished  by  Morse  and  Talbot,  shows  the 
composition  of  the  most  widely  known  infant  foods  on  the  market: 

Fat.  Sugar.  Protein.  Starch.  Ash. 


Condensed  milk: 

Eagle  Brand   . 

9.61 

54.94 

S.Ol 

1.78 

St.  Charles  Brand 

8.70 

10.95 

8.80 

1.40 

Ramogen     .... 

16.50 

34.65 

7.00 

1.50 

A'lammala    .... 

12.12 

55.34 

24.35 

4.93 

Horlick's  Malted  Milk 

8.78 

67.95 

16.35 

3.86 

Mellin's  Food  . 

0.16 

79.57 

10.35 

4.30 

Mead's  Dextro-Maltose 

93.00 

2.00 

Laibose        .... 

17.00 

55.00 

18.00 

4.00 

Allenbury's  Food  No.  1 

18.60 

66.55 

10.66 

3.95 

Allenbury's  Food  No.  2 

15.88 

70.90 

9.90 

3.71 

Allenbury's  Food  No.  3 

1.05 

25.11 

10.23 

60 

01 

0.60 

Eskay's    Albuminized 

Food         .... 

3.52 

55.82 

6.70 

29 

90 

0.99 

Nestle's  Food    . 

5.50 

58.93 

14.34 

15 

39 

2.03 

Ridge's  Food    . 

0.26 

7.80 

12.50 

73 

67 

0.61 

Benger's  Food 

0.92 

3 .  34 

12.12 

77 

02 

0.97 

Imperial  Granum  . 

1.04 

1.80 

14.00 

73 

54 

0.39 

Wheat  Flour     . 

1.00 

11.40 

76 

10 

0.50 

PROPRIETARY  FOODS  177 

It  is  readily  apparent  from  the  preceding  analysis  of  these  foods  that 
no  individual  preparation  contains  the  proper  amount  or  proportion 
of  food  elements  to  sustain  the  life  of  an  infant  and  provide  for  its 
growth  for  any  great  length  of  time.  Most  of  them  show  a  deficiency 
in  fats  and  an  excess  of  carbohydrates  which  prohibit  their  continued 
use,  inasmuch  as  the  proportion  of  fat  in  an  infant's  food  is  a  most 
important  consideration. 

The  proteins  in  these  preparations  are  either  heated  and  dried 
proteins  of  cow's  milk,  which  are  most  indigestible,  or  vegetable  pro- 
teins which  are  unsuitable  for  the  infant.  It  is  not  uncommon  to  hear 
of  infants  who  have  apparently  thriven  on  one  particular  food;  but 
these  cases  do  not  prove  that  patent  foods  are  better  than  modified 
milk;  on  the  contrary,  they  should  be  regarded  as  occasional  instances 
in  which  the  particular  food  given  has  fortunately  contained  the 
various  food  elements  in  proper  proportion  and  combination  for  the 
individual  case. 

The  milk  modifiers,  such  as  Eskay's  Food,  are,  perhaps,  least 
objectionable,  since  they  provide  starch  in  a  form  easy  of  digestion, 
and  the  food  is  added  to  fresh  cow's  milk. 

Patent  foods  are  used  principally  by  the  careful  practitioner  at  the 
weaning  period ;  when  there  is  milk  idiosyncrasy ;  or  as  a  substitute  for 
milk  during  an  acute  illness;  but  their  routine  use  in  infant  feeding  is 
to  be  condemned,  not  only  on  account  of  the  faulty  composition  of 
these  preparations,  but  because  of  the  careless  prescribing  it  leads  to 
in  treating  infants.  Another  great  objection  is  the  cost  of  the  food, 
which  far  exceeds  that  of  modified  milk. 

Meat  Preparations. — Meat  preparations  have  no  place  in  the  feed- 
ing of  a  normal  infant,  but  they  are  important  additions  to  the  diet 
of  the  sick  child  when  cow's  milk  must  be  temporarily  withdrawn. 
Raw  meat  juice  is  the  most  popular  preparation,  and  is  made  by 
adding  an  equal  quantity  of  cold  water  to  finely  ground  raw^  beef, 
and  allowing  it  to  stand  for  half  an  hour,  after  which  the  juice  is 
squeezed  out  through  muslin. 

Meat  juice,  thus  made,  contains  approximately  5  per  cent,  proteins, 
3  per  cent,  extractive  matter,  and  0.7  perxcent.  salts,  and  may  be  given 
alone  or  combined  with  whey,  cream,  barley-water,  or  even  with 
Mellin's  or  some  other  prepared  food.  Meat  juice  is  especially  valuable 
in  the  treatment  of  scurvy,  since  it  possesses  distinct  antiscorbutic 
properties. 

Proprietary  meat  preparations  occasionally  give  good  results,  but 
are  not  nearly  as  suitable  for  the  infant  as  the  fresh  juice,  and  have  no 
antiscorbutic  effect. 

]\Ieat  broths,  made  from  mutton,  beef,  and  veal,  also  chicken  broth, 
are  all  useful  when  milk  feedings  are  temporarily  contraindicated  on 
account  of  gastro-intestinal  disturbances.  Several  prepared  beef 
juices  are  on  the  market,  the  most  popular  of  which  are  Valentine's, 
Brand's,  Armour's,  Wyeth's  and  Burgoynes's,  also  the  preparations 
known  as  Puro  and  Bovinine. 
12 


178  INFANT  FEEDING 

Malt  Soup. — IMalt  soup  is  a  proprietary  food  containing  wheat  flour, 
malt,  and  milk,  upon  which  an  infant  ca-n  be  fed  for  several  months 
if  the  child's  stomach  tolerates  it.  It  is  indicated  particularly  in  rachitis 
and  in  dyspeptic  infants  who  have  suffered  greatly  from  malnutrition. 

To  make  malt  soup,  4  ounces  of  wheat  flour  should  be  mixed 
thoroughly  with  a  quart  of  milk,  and  strained  through  gauze.  To  this 
is  added  a  quart  of  warm  water  containing  6  ounces  of  thick  malt 
and  30  grains  of  potassium  carbonate  in  solution.  For  young' infants 
one-half  of  this  quantity  can,  be  made  up,  and  more  water  and  less 
milk  may  be  used.  As  the  infant  grows  older,  and  the  gastro-intestinal 
tract  becomes  stronger,  more  milk  should  be  added  to  the  soup, 
but  the  amount  of  wheat  and  flour  need  not  be  changed. 

ARTIFICIAL  FEEDING. 

Artificial  infant  feeding  is  the  substitution  of  any  other  form  of 
nourishment  for  breast  milk,  which  is  the  normal  food  of  infants. 
There  are  but  few  food  elements,  however,  and  the  baby's  food  must 
contain  some  of  them,  perhaps  all  of  them,  but  should  not  contain 
any  other  elements.  These  food  elements  are  fats,  carbohydrates, 
proteins,  and  salts,  and  they  must  be  given  in  correct  quantity  and 
proportion.  The  infant  must  also  be  given  sufficient  food  to  make 
it  thrive  and  gain  weight,  and  this  amount  can  be  determined  by 
calculating  the  caloric  value  of  the  food  given. 

Since  the  milk  from  the  mother's  breast  for  a  period  of  twelve  to 
fourteen  months  shows  no  variation  in  composition,  it  would  seem  as 
though  the  artificial  food  substituted  for  breast  milk  should  be  made  to 
resemble  human  milk  in  composition,  and  that  it  would  need  but 
little  change;  but  this  is  not  the  case,  for  no  food  has  been  discovered 
which  is  even  approximately  a  substitute  for  breast  milk. 

A  modification  of  cow's  milk  that  will  make  its  composition  resemble 
human  milk  is  the  most  satisfactory  substitute  yet  discovered,  although 
it  is  neither  as  nutritious  nor  digestible  as  human  milk,  is  not  sterile, 
and  contains  none  of  the  biological  constituents.  Mare's  milk  resembles 
human  milk  more  closely  than  does  cow's  milk;  but  it  is  rarely  used 
because  of  the  difficulty  in  obtaining  it.  Goat's  milk  bears  a  slightly 
closer  resemblance  to  human  milk  than  does  cow's  milk,  but  this, 
too,  is  rather  difficult  to  obtain,  and  must  also  be  modified,  therefore 
its  use  in  infant  feeding  is  not  popular. 

jNIodified  cow's  milk  is  consequently  the  best  practicable  substitute 
iox  human  milk.  Proprietary  foods  and  condensed  milk  are  rarely 
used  by  the  physician  for  any  considerable  time,  while  other  prepara- 
tions, such  as  dextrinized  gruels,  malt  soup,  albumin-water,  meat 
preparations,  albumin  milk,  barley-water,  and  rice-water  are  used 
principally  as  substitutes  when  milk  is  temporarily  suspended  in  the 
course  of  diseases  of  the  gastro-intestinal  tract. 

Variety  of  Fats,  Carbohydrates,  and  Proteins. — Fats. — The  character 
of  the  fats  in  a  feeding  mixture  can  not  be  changed,  but  the  emulsion 


CALORIC  FEEDING  179 

can  be  made  more  complete  by  homogenization,  which  reduces  the 
fat  droplets  to  a  very  small  size.  Olive  oil,  which  is  another  form  of 
fat,  may  be  introduced  into  the  infant's  food  by  homogenization. 

Carbohydrates. — Milk  Sugar. — Lactose  is  the  most  suitable  form  of 
sugar  to  insure  the  growth  of  the  infant,  because  it  is  more  completely 
absorbed  than  other  disaccharides,  and  it  favors  the  growth  of  the 
normal  intestinal  flora,  thus  aiding  digestion.  Moreover,  few  of  the 
other  organisms  in  the  intestinal  tract  thrive  upon  it,  so  that  to 
a  certain  degree  it  protects  the  tract  from  the  development  of 
undesirable  bacteria. 

Maltose  is  too  expensive  to  be  used  alone  in  infant  feeding,  and  is 
usually  combined  with  dextrines.  On  ingestion  it  is  immediately 
split  up  into  dextrose,  and  has,  therefore,  more  of  a  laxative  effect 
than  the  dextrines,  and  is  less  favorable  to  the  growth  of  normal 
intestinal  flora.  Dextrin-maltose  is  valuable  in  cases  where  intestinal 
disturbances  are  due  to  fermentation  of  milk  sugar. 

Cane  Sugar. — This  is  the  least  desirable  of  the  various  sugars  because 
it  undergoes  alcoholic  fermentation  instead  of  lactic  acid  fermentation, 
and  does  not  promote  the  growth  of  normal  intestinal  flora.  There 
are  no  indications  for  using  cane  sugar  in  infant  feeding. 

Starch. — Starch  should  not  be  given  to  mfants  under  four  months 
of  age,  and  it  is  inadvisable  to  allow  any  large  quantity  of  starchy 
food  until  after  the  first  year.  On  the  other  hand,  some  starch  should 
be  included  in  the  food  after  the  sixth  month,  but  must  be  given  in 
definite  amounts,  the  same  as  fats  and  proteins.  Starch  is  especially 
indicated  in  cases  of  sugar  fermentation  and  intolerance  to  sugar. 
It  is  usually  given  as  a  cereal  cooked  in  water,  such  as  oatmeal,  or  as 
rice-water,  or  barley-water,  or  in  the  form  of  gruel.  An  excessive 
amount  of  starch  may  cause  constipation  and  marked  disturbance  of 
digestion  and  nutrition.  ■ 

Proteins. — The  protein  of  cow's  milk  is  less  easy  of  digestion  than 
that  of  human  milk  on  account  of  the  greater  amount  of  casein  which 
it  contains,  resulting  in  the  formation  of  large,  tough  curds.  Whey 
protein  is  not  coagulable  by  rennin,  therefore  is  the  best  form  of  protein 
to  give  the  infant,  since  it  does  not  form  curds. 

CALORIC  FEEDING. 

This  is  a  method  of  providing  nourishment  for  the  infant  by  giving 
it  a  food  which  contains  the  number  of  calories  suitable  for  the 
individual  case;  but  the  caloric  requirements  of  an  infant  are  in- 
fluenced by  so  many  difterent  factors  that  the  caloric  method  of  feeding 
is  not  practicable.  It  offers,  however,  a  method  of  determining  whether 
a  child  is  overfed  or  underfed,  and  can  be  employed  when  an  infant 
suffers  from  persistent  gastro-intestinal  disturbances,  or  whenever  a 
baby  fails  to  tlu'ive. 

The  large  calorie,  which  is  the  amount  of  heat  necessary  to  raise 
one  kilogram  of  water  1  c.c,  is  the  one  used  in  infant  feeding.    The 


180  INFANT  FEEDING 

normal  infant  requires  from  100  to  120  such  calories  per  kilogram  of 
its  body  weight  during  the  first  six  months  in  order  to  thrive.  From  its 
sixth  month  until  it  is  one  year  old  it  needs  100  calories,  and  90 
calories  during  the  second  year. 

The  number  of  calories  required  by  an  infant  in  order  that  it  may 
gain  weight  depends  also  upon  its  state  of  health.  Fat  babies  never 
need  more  than  90  calories  per  kilogram,  and  the  fatter  they  are  the 
less  calories  they  need  in  order  to  gain;  while  thin  babies  may  require 
from  140  to  160  calories  per  kilogram  in  order  to  gain,  and  the  thinner 
the  baby  the  more  calories  necessary. 

Babies  that  have  been  underfed,  or  are  recovering  from  some 
debilitating  illness,  also  require  temporarily  more  calories  than  healthy 
normal  infants,  and  the  active  child  needs  more  than  the  quiet  one; 
so  more  food  must  be  given  the  infant  which  cries  most  of  the  day  and 
is  restless  at  night  than  the  baby  that  sleeps  nearly  all  of  both  day 
and  night. 

The  caloric  value  of  modified  milk  mixtures  may  be  quickly  deter- 
mined by  means  of  the  formula  recommended  by  Fraley,  The  letters 
"F,"  "P,"  and  "S"  represent  the  respective  percentages  of  fats,  pro- 
teins, and  sugar,  and  the  letter  "Q"  the  total  quantity  of  food.  Thi? 
formula  follows: 

2F  +  P  +  S  X  liQ  =  Calories. 

The  caloric  value  of  a  20-ounce  mixture  containing  3  per  cent,  fat, 
1  per  cent,  protein,  and  6  per  cent,  sugar  can  be  calculated  as  follows: 

2  X  F  (3)  =  6  +  P  (1)  =  7  +  S  (6)  =  13  X  IJQ  (25)  =  325  calories. 

HOME  MODIFICATION  OF  MILK. 

Milk  can  be  prepared  at  home  with  such  accuracy  that  most  infants 
will  thrive  upon  it,  and  percentage  formulas  are  easily  obtained.  The 
excuse  is  sometimes  made  that  modification  of  milk  is  too  difficult  a 
procedure  to  be  attempted  at  home,  but  I  have  not  found  this  to  be 
the  case. 

The  actual  quantity  of  the  various  food  elements  to  be  used  must 
be  carefully  calculated,  however,  instead  of  merely  writing  percentages 
on  a  prescription  blank,  and  the  mother  must  be  told  just  how  much 
cream,  skimmed  milk,  water,  lime-water,  and  sugar  of  milk  to  use. 
She  must  also  be  instructed  how  to  secure  a  certain  percentage  of  fat 
cream  from  the  top  of  a  quart  bottle  of  milk.  A  4  per  cent,  fat  milk 
will,  upon  standing,  yield  12  per  cent,  of  fat  in  the  upper  8  ounces  of  a 
quart  bottle,  20  per  cent,  of  fat  in  the  upper  5  ounces,  and  16  per  cent, 
of  fat  in  the  upper  6  ounces;  and  with  cream  of  these  varying  degrees 
of  fat  content  most  milk  mixtures  can  be  made.  A  cream  dipper  should 
be  used  to  obtain  the  cream,  and  the  fat-free,  or  skimmed,  milk  should 
be  gotten  from  the  very  bottom  of  the  bottle. 

In  measuring  the  milk  sugar  a  rounded  tablespoonful  is  considered 
to  weigh  half  an  ounce.  Therefore,  in  prescribing  a  modified  milk 
mixture  to  be  made  at  home,  the  physician  not  only  states  the  exact 


LABORATORY   METHOD  OF   MODIFICATION   OF  MILK      ISl 

percentage  of  the  \  arioiis  food  elements  to  be  usedj  bnt  estimates  the 
quantity  of  each  ingredient  to  be  put  in  the  mixture,  and  writes  his 
directions  accordingly.     Such  a  prescription  follows: 

Cream  (12  per  cent,  fat) 5  ounces 

Fat-free  milk .  3  ounces 

Sugar  of  milk 2  tablespoonfuls 

Lime-water 1  ounce 

Water  (boiled)  enough  to  make 20  ounces 

Three  ounces  of  this  may  be  given  every  three  hours.  Any  percentage 
of  cream  ma}'  be  used,  but,  for  practical  purposes,  as  well  as  economy, 
it  is  generally  advisable  to  make  our  home  modification  with 

12  per  cent,  cream 

Fat-free  milk  ' 

Milk  sugar 

Lime-water 

Water 

With  these  ingredients  almost  any  desired  percentages  may  be  obtained. 

LABORATORY  METHOD  OF  MODIFICATION  OF  MILK. 

The  physician  who  has  the  advantage  of  proximity  to  a  milk  labora- 
tory in  which  milk  formulas  are  prepared  must  first  decide  what 
percentage  of  fats,  carbohydrates,  and  proteins  will  be  suited  to  the 
infant's  case,  and  how  much  he  wishes  to  give  the  infant  in  twenty-four 
hours.  The  amount  to  be  given  at  each  feeding  should  be  determined, 
and  the  caloric  value  of  such  a  mixture  also  calculated,  in  order  that 
the  infant  may  be  neither  overfed  nor  underfed. 

The  amount  of  protein  in  a  mixture  for  the  newborn  infant  must 
be  extremely  small,  and  very  little  fats  should  be  given.  The  carbo- 
hydrates are  reduced  to  5  per  cent,  for  the  first  few  weeks,  after  which 
6,  and  later  7  per  cent,  are  prescribed,  and  this  latter  percentage  remains 
practically  stationary  throughout  infancy,  although  the  percentage  of 
fats  and  proteins  is  increased  at  various  intervals.  In  addition  to 
determining  the  percentage  of  these  various  food  elements,  the  phy- 
sician must  decide  what  kind  of  sugar  is  to  be  used,  also  whether  or 
not  part  of  the  protein  shall  be  in  the  form  of  whey  protein. 

He  must  also  decide  whether  or  not  an  alkali  shall  be  added,  and 
whether  the  milk  shall  be  given  raw,  pasteurized,  or  boiled.  Having 
decided  all  these  points,  it  is  only  necessary  to  write  a  prescription 
on  the  blank  furnished  by  most  laboratories,  stating  what  the  com- 
position of  the  formula  is  to  be,  and  how  often  it  is  to  be  given. 

There  is  no  doubt  that  the  milk  laboratory  prepares  the  milk 
mixture  more  accurately  than  does  the  mother,  but  the  expense 
attached  is  too  great  for  poor  people.  A  table,  giving  approximately 
the  composition  and  percentages  of  milk  mixtures,  with  the  number  of 
feedings  at  different  ages,  is  here  given.  But  the  physician  must 
remember  that  no  two  infants  can  be  fed  alike,  and  that  these  figures 
are  only  approximately  correct  for  the  normal  healthy  infant.  A  form 
of  prescription  blank  to  be  used  in  conjunction  with  laboratory 
modification  is  here  appended. 


182 


INFANT  FEEDING 


R— 

Fats 


Carbohydrates . 

Dextrinize 

Proteins       .... 

Peptonize 

Sodium  citrate 

Sodium  bicarbonate     . 

Lime-water 

Lactic  acid  bacilli 
Heat  at  °  F. 

Number  of  feedings 
Amount  at  each  feeding 


Date 


For. 


(lactose, 
maltose, 
sucrose, 
dextrose. 
(starch, 
whey, 
casein, 
per  cent, 
per  cent. 
^  per  cent. 
\  per  cent, 
per  cent, 
per  cent. 


of  milk  and  cream, 
of  total  mixture, 
of  milk  and  cream, 
of  total  mixture, 
of  milk  and  cream, 
of  total  mixture. 


M.D. 


Amount  at  each 
feeding. 

M 

Total  quantity, 
24  hours. 

s 

fe 

1 

i 

3 
O 

1 

a) 

£ 

1 

J 

1 
2 

-3 
t 

>> 

Q 

1 

O 

S 
o 

6 

1 

o 
"3 

'3 
□■ 

o 

s 
6 

First  we  ek  to  fo 

urth  w 

eek: 

i 

1.0 

5.0 

.25 

H 

45 

10 

2 

2 

15 

450 

.138.6 

330 

1.0 

6.0 

.50 

li 

45 

10 

2 

2 

15 

450 

1.25 

7.0 

.75 

2 

60 

8 

2 

2 

16 

480 

<      to 

^    to 

1..5 

7.0 

1.0 

2i 

75 

8 

2 

2| 

20 

600 

2.0 

7.0 

1.0 

3 

90 

8 

2 

2| 

24 

720 

.370 

.370 

Second 

month 

to  four 

th   mo 

nth': 

2.0 

7.0 

1.0 

3| 

105 

7 

3 

24| 

735 

'377 

'370 

2.25 

7.0 

1.0 

4 

120 

7 

3 

28 

840 

2.5 

7.0 

1.25 

4| 

135 

7 

3 

31| 

945     ' 

^     to 

^    to 

3.0 

7.0 

1.25 

5 

150 

7 

3 

35 

1050 

j 

3.0 

7.0 

1.5 

5 

150 

7 

3 

35 

1050 

[658 

520 

Fifth  m 

onth: 

[606 

'520 

3.5           7.0 

1.5 

5 

150 

6 

0 

3 

30 

900     i 

<     to 

<    to 

Sixth  month: 

1 

3.5           7.0 

1.75 

6 

180 

6 

0 

3 

36 

1080     { 

J38       i 

576 

Seventh  month: 

I 

799       1 

'576 

3.5      I     7.0 

2.0 

6 

180 

6 

0 

3 

36 

1080 

i 
to        i 

•    to 

Eighth 

month : 

4.0 

7.0 

2.25 

7| 

225 

6 

0 

3 

45 

1350     , 

,  1017 

.640 

Ninth 

month  t 

0  twelf 

th    mo 

nth: 

4.5 

7.0 

2.5 

8 

240 

5 

0 

4 

40 

1200 

[952 

[560 

4.0 

6.0 

3.0 

8| 

255 

5 

0 

4 

42| 

1275 

\    to      ! 

i    to 

4.0      1     4.5 

3.5 

9 

270 

5 

0 

4 

45 

1350     j 

[945 

1  640 

Feeding  premature  infants. 


Thirtiet 

h  week: 

1.0 

3.0 

0.25 

Heat  thirty  minutes  at  155°  F.,  24  feedings  of  2  drams  each. 

Thirty- 

second 

week: 

1.0 

4.0 

0.50 

Heat  thirty  minutes  at  155  °  F. ,  24  feedings  of  2  drams  each. 

Thirty- 

fourth 

week: 

15.0 

45.0 

0.75 

Heat  thirty  minutes  at  155°  F.,  16  feedings  of  5  drams  each. 

These  formulas  should  all  contain  5  per  cent,  of  lime-water. 


CARE  OF  BOTTLES  AND   NIPPLES  183 

FEEDING  AFTER  THE  WEANING  PERIOD. 

From  the  ninth  to  the  twelfth  month  the  food  should  consist  of 
whole  milk  diluted  with  one-seventh  its  bulk  of  water.  In  addition 
cereals,  such  as  Imperial  Granum,  oatmeal,  and  cream  of  wheat  may 
be  given  once  daily,  and  orange  juice  and  beef  juice  three  times  a  week. 

From  the  twelfth  to  the  eighteenth  month  the  child  is  fed  four  or 
five  times  daily,  and  may  be  allowed  soft-boiled  eggs,  plain  crackers, 
bread  and  butter,  milk  custards;  clear  beef,  mutton,  or  chicken  soup; 
prune  juice,  baked  apple:  baked  potato.  When  all  of  the  teeth  have 
appeared,  and  the  food  can  be  properly  masticated,  lamb  chop,  white 
meat  of  chicken,  and  underdone  beafsteak  may  be  given,  also  green 
vegetables,  such  as  beans,  spinach,  asparagus,  potatoes,  and  peas. 

After  the  fifth  or  sixth  year  three  or  four  meals  are  sufficient,  and 
the  child  may  take  well-cooked  vegetable  soups,  meat,  fish,  poultry, 
fresh  vegetables,  ripe  fruits,  puddings,  and  ice  cream  once  or  twice  a 
wee^. 

CARE    OF   BOTTLES    AND    NIPPLES. 

After  use,  all  bottles  and  nipples  should  be  scrubbed  with  very  hot 
water  and  a  brush,  and  put  into  cool,  sterile  water  containing  a  little 
sodium  bicarbonate.  The  bottles  should  be  boiled  for  ten  minutes 
just  before  the  day's  milk  supply  is  prepared. 

The  nipple  should  be  of  rubber,  and  thin  enough  to  be  easily  turned 
inside  out  when  cleansed.  The  opening  should  be  only  large  enough 
to  allow  the  milk  to  trickle  out  drop  by  drop  when  the  bottle  is  inverted. 
Any  complicated  nipple  or  any  tubing  which  extends  into  or  from  the 
nursing  bottle  is  difficult  to  clean  and  positively  harmful. 

It  is  usually  unnecessary  to  cleanse  the  mouth  of  a  child  either  before 
or  after  feeding,  provided  the  oral  mucous  membrane  is  normal,  the 
mother's  nipple  healthy,  and  that,  if  bottle-fed,  the  rubber  nipple  is 
properly  cared  for.  If,  however,  the  mother's  nipple  is  sore,  eroded, 
or  cracked,  and  a  nipple  shield  is  not  used,  the  child's  mouth  should 
be  gently  cleansed  with  plain  sterile  water  just  before  feeding. 


CHAPTER  IX. 
NORMAL  DIGESTION. 

The  newborn  infant  is  not  a  perfectly  developed  individual,  but 
is  still  in  the  stage  of  development.  This  is  true  as  regards  both  its 
digestive  organs  and  their  functions.  Yet  these  organs  are  called 
upon  not  only  to  sustain  life  by  repairing  tissue  waste,  as  in  the 
adult,  but  also  to  provide  sufficient  material  for  promoting  growth 
and  proper  development. 

When  we  consider  that  diu-ing  the  first  year  of  life  the  body  weight 
must  approximately  be  trebled,  we  understand  why  the  delicate, 
immature  digestive  apparatus  of  an  infant  is  so  easily  upset,  and  the 
importance  of  proper  nutrition  during  this  period  becomes  evident. 
In  order  to  avoid  overtaxing  this  immature  function,  Nature  has 
provided  in  mother's  milk  all  the  necessary  food  elements  in  proper 
proportion  and  in  assimilable  form.  She  also  furnishes  lipase,  dias- 
tase, and,  in  all  probability,  a  protein-digesting  ferment,  as  well  as 
certain  substances  which  no  doubt  act  as  protectives  against  diseases 
of  the  intestinal  tract. 

The  Oral  Cavity. — The  absence  of  teeth,  the  peculiar  fat  polster 
in  the  cheeks,  which  is  seen  even  in  marasmic  babies,  and  other  ana- 
tomical conditions  plainly  show  that  the  oral  cavity  is  at  first  intended 
for  the  reception  of  liquid  food  only,  its  mechanism  being  purely 
suctional.  The  child  grasps  the  nipple  between  the  tongue  and  the 
hard  palate,  and  by  a  downward  movement  of  the  lower  jaw,  aided 
by  the  contraction  of  the  muscles  in  the  floor  of  the  mouth  and  later 
on  by  deep  inspirations,  creates  a  partial  vacuum,  and  thus  the  milk 
is  made  to  flow  from  the  galactiferous  ducts  into  the  nursling's  mouth. 

Sucking  is,  therefore,  only  possible  when  the  nose  is  free  for  respira- 
tion and  the  palate  and  the  floor  of  the  mouth  are  perfectly  intact. 
Hare-lip,  cleft-palate,  nasal  obstructions,  and  adenoids  greatly  inter- 
fere with  nursing  and  may  even  make  it  impossible.  The  mouth  is 
merely  the  natural  entrance  to  the  digestive  organs,  and  at  birth  does 
not  aid  digestion  by  salivary  secretion;  although  the  salivary  glands 
are  present  and  apparently  well-developed,  their  secretory  function 
■  is  not  yet  fully  established,  consequently  the  mucous  membrane  of 
the  mouth  is  rather  dry,  the  small  amount  of  salivary  amylase  or 
ptyalin  contained  in  the  saliva  clearly  indicating  that  the  latter  is 
not  ready  to  be  utilized  for  starch  digestion. 

After  the  third  or  fourth  month — toward  the  beginning  of  den- 
tition— the  salivary  secretion  increases  markedly  in  quantity  and  its 
characteristic  quality  is  intensified.  Even  then  it  probably  plays  but 
an  insignificant  role  in  digestion,  because  very  little  of  it  is  swallowed. 


GASTRIC  DIGESTION  185 

the  greater  ])art  Howiiig  out  of  the  month  iimised  ((h'ooliiig).  1'owcmJ 
the  latter  part  of  the  first  year  the  amylolytic  function  is  fully  estab- 
lished and  is  comparatively  as  active  as  in  later  life  in  the  partial 
conversion  of  insoluble  starch  into  soluble  starch — er^throdextrin, 
achroodextrin,  and  maltose. 

Dry  food  stimulates  the  secretion  of  saliva,  which  is  usually  alkaline 
or  neutral,  while  food  containing  much  water  excites  but  little  flow. 
Salivary  amylase  or  ptyalin,  the  active  enzyme  of  saliva,  the  digesti\'e 
power  of  which  is  limited  to  starchy  food,  acts  in  a  neutral  medium, 
or  in  a  slightly  acid  solution.  It  continues  to  act  in  the  stomach 
until  the  gastric  contents  have  been  acidified,  which  occurs  ordinarily 
in  from  one-half  to  one  hour  after  a  meal.  It  may  be  worth  men- 
tioning in  this  connection  that  the  reaction  of  the  oral  cavity  has  been 
found  to  be  slightly  acid  in  95  per  cent,  of  infants  whose  mouths  had 
not  been  thoroughly  cleansed  after  feeding. 

Dentition  in  the  normal  infant  is  of  interest  chiefly  on  account  of 
the  importance  w^hich  parents  are  ever  ready  to  ascribe  to  it  as  the 
cause  of  convulsions  and  gastro-intestinal  disturbances.  The  erup- 
tion of  the  temporary  teeth  is  a  physiological  process.  The  first  tooth 
usually  appears  dm*ing  the  sixth  month,  but  variations  in  time  from 
the  fifth  to  the  eighth  month  are  not  abnormal.  The  remaining  teeth 
appear  in  groups  at  more  or  less  regular  intervals  in  the  following 
order:  lower  incisors,  upper  incisors,  canines,  and  molars.  At  the 
age  of  two  and  a  half  years  all  of  the  teeth  should  have  been  cut. 
Teething  is  therefore  an  almost  continuous  process  for  about  eighteen 
to  twenty-four  months.  This  fact  alone  shows  the  fallacy  of  attribut- 
ing to  its  influence  diarrhea  and  other  diseases  which  are  merely 
coincidental.  Forcheimer  says,  "Dentition  produces  teeth,  nothing 
more." 

On  the  other  hand,  dentition  may  be  painful,  especially  in  the  case 
of  the  narrow  palatal  arches  so  frequently  seen  in  children  suffering 
from  adenoids  or  other  nasal  obstructions.  Sometimes  it  takes  a 
tooth  days  and  weeks  actually  to  penetrate  the  mucous  membrane. 
A  dry,  hot  mouth,  a  peculiar  irritability,  fretfulness,  and  other  slight 
disturbances  of  health  seem  to  occur  so  often  during  dentition  that 
one  cannot  doubt  a  certain  causal  relationship  between  it  and  the 
other  conditions;  and  it  can  be  readily  understood  that  infants  with 
inherited  neurotic  and  spasmophilic  tendencies  may  show  even  more 
severe  symptoms  of  disturbance  of  their  unstable  equilibrium. 

The  sense  of  taste  is  well  developed  at  birth,  and  probably  that  of 
smell  also. 

There  is  little  to  be  said  about  the  esophagus  except  that  its  epithel- 
ium is  soft  and  delicate,  and  that  the  glands  are  usually  lacking. 

Gastric  Digestion. — Gastric  digestion  has  been  said  to  be  insignificant 
in  infants,  the  stomach  serving  merely  as  a  reservoir  for  the  milk, 
which  is  passed  into  the  intestines  at  convenient  intervals,  and  in 
such  quantities  as  the  duodenum  can  best  take  care  of.  While  it  is 
true  that  the  organ  does  not  play  so  important  a  role  in  the  digestion 


186  NORMAL  DIGESTION 

of  infants  as  in  that  of  adults,  and  that  its  mechanical  and  chemical 
processes  are  only  preliminary  to  intestinal  digestion,  it  has  been  con- 
vincingly demonstrated  by  Pawlow  and  his  school  that  the  functions 
of  all  the  different  parts  of  the  digestive  apparatus  are  interrelated 
and  dependent  upon  each  other  to  a  great  extent. 

A  description  of  a  single  physiologic  function  must,  therefore,  be 
more  or  less  incomplete  unless  due  consideration  be  given  at  the  same 
time  to  all  of  the  other  supplementary  or  complementary  processes 
involved.  The  process  of  digestion  in  infants,  on  the  whole,  is  by  no 
means  as  yet  clearly  understood,  in  spite  of  the  most  painstaking  and 
elaborate  investigations. 

The  majority  of  observations  and  conclusions  are  based  either  on 
lavage  of  the  infant's  stomach,  limited  necessarily  to  short  periods, 
or  on  animal  experimentations.  The  latter  are  of  comparatively  little 
use,  because  animals  suffer  little  from  digestive  disorders,  their  diges- 
tive organs  being  much  more  fully  developed  at  birth,  and  they  can 
assimilate  adult  food  at  a  much  earlier  period  of  their  lives  than  do 
infants. 

Moreover,  it  must  be  borne  in  mind  that  even  apparently  normal 
infants  differ  individually  as  to  their  digestive  capabilities,  at  least  as 
much  as  adults,  and  that  in  different  infants  the  secretory  functions 
are  not  equally  developed  in  the  formative  stage  of  the  first  year  of 
life. 


GASTRIC   DIGESTION    (ANATOMICAL   AND   PHYSIOLOGICAL 
PECULIARITIES). 

Considering  the  ease  with  which  infants  vomit,  the  position  and 
form  of  the  stomach  are  matters  of  interest.  Its  position  is  more  verti- 
cal than  oblique,  the  cardiac  end  is  well  fixed,  and  is  slightly  to  the 
left  of  the  tenth  dorsal  vertebra;  the  more  freely  movable  pylorus  is 
located  at  a  point  half  way  between  the  ensiform  cartilage  and  the 
umbilicus,  and  in  front  or  even  slightly  to  the  left  of  the  spinal  column. 
In  form  it  stands  midway  between  the  tubular  type  of  fetal  life  and 
the  pouch-like  adult  organ. 

At  birth  the  stomach  is  rather  small,  its  fundus  and  muscles  being 
only  slightly  developed,  but  it  grows  rapidly,  except  when  insufficient 
quantities  of  food  are  given  for  a  prolonged  period.  The  peculiarities 
of  the  adult  shape  and  position  appear  in  early  childhood,  and  it  is 
noteworthy  that  the  pyloric  opening  is  proportionately  much  wider 
during  the  first  year  than  it  is  in  later  life. 

The  problem  of  gastric  capacity  has  not  been  definitely  solved  by 
any  system  of  measurement.  This  is  probably  no  loss,  from  a'  clinical 
point  of  view,  for,  as  a  rule,  an  infant  instinctively  ceases  to  feed  before 
its  stomach  is  mathematically  full.  The  capacity  is  said  to  be  greater 
in  the  artificially  fed  baby  than  in  the  breast-fed  infant  (we  think 
not  necessarily  so  when  properly  managed),  and  to  increase  rapidly 
during  the  first  three  months,  slowly  in  the  fourth,  practically  not  at 


GASTBJC  DIGESTION  187 

all  (luring  the  next  two  mouths,  aud  then  again  increasing  until  the 
adult  size  is  attained,  as  is  shown  in  the  following  table: 

At  birth 1    ounce 

At  four  weeks 2j  ounces 

At  eight  weeks 3j 

At  three  months 4 

At  four  months    . 5 

At  five  months 5^ 

At  six  months 5j 

At  seven  months ' 6j 

At  eight  months 7 

At  nine  montlis .-      .  >    .       .      .      .      .      .  7? 

At  ten  months 7f 

At  eleven  months      . 8j 

At  twelve  months      . 9 

For  practical  purposes  it  is  sufficient  to  remember  these  figures: 

At  birth 1-2  ounces 

At  three  months 4  " 

At  six  months ,  .       .      .       .      .       .       .      .  6    ,       " 

At  twelve  months 9  " 

The  stomach  is  a  muscular  organ.  Its  motor  function  is  chiefly 
exerted  in  mixing  the  food  and  expelling  it  into  the  duodenum  in  proper 
quantities  and  at  convenient  intervals.  According  to  Cannon,  the 
pyloric  mechanism  seems  to  be  controlled  by  hydrochloric  acid.  A 
certain  acidity  of  the  stomach  contents  in  the  pyloric  region,  due  to 
its  admixtm-e  with  free  hydrochloric  acid,  causes  the  pylorus  to  open, 
while  an  acid  reaction  on  the  duodenal  side  causes  it  to  close  and  to 
remain  closed  until  the  acid  is  neutralized.  A  high  fat  percentage 
retards  the  passage  of  food  through  the  pylorus. 

Pawlow  has  demonstrated  that  the  quantity  and  the  properties  of 
the  digestive  secretions  vary  with  the  character  of  the  food  to  be 
digested;  that  is,  the  secretions  produced  by  different  kinds  of  food 
vary  in  amount,  in  acidity,  and  in  their  digestive  action.  Quite  apart 
from  psychical  stimulation,  it  seems  that  certain  foods  when  taken  into 
the  stomach  cause  a  secretion  of  the  gastric  juice  owing  to  the  secre- 
tagogues  they  contain.  Meat  extracts,  soups,  water  and  meat  juices 
are  especially  active;  milk,  and  egg  albumen,  less  so.^ 

The  gastric  secretion  begins  about  five  to  seven  minutes  after  the 
ingestion  of  food,  and  increases  rapidly,  reaching  its  maximum  of 
digestive  power  in  about  two  hours,  after  which  the  flow  rapidly 
decreases.  The  development  of  the  glands  in  the  mucous  membrane 
of  the  stomach  is  rarely  equally  advanced  in  infants  of  the  same  age. 
Every  baby  is  a  law  unto  itself  in  this  respect,  as  well  as  in  respect 
to  its  digestive  and  other  assimilative  powers;  in  other  words,  there 
exist  individual  differences  in  the  development  of  the  gastric,  the 
glandular,  and  digestive  functions  of  the  infant  which  to  some  extent 
explain  the  different  findings  of  various  investigators. 

1  The  secretion  produced  by  bread,  though  less  in  quantity  than  by  meat,  possesses  a 
greater  digestive  action. 


188  NORMAL  DIGESTIOX 

Tlie  acid  reaction  of  the  stoniacli  contents  in  the  nf)rmal  hifant  is 
due  to  hydrochloric  acid,  the  i>resence  of  which  can  be  easily  proved 
and  its  quantity  determined.  Lactic  acid,  probably  produced  by  the 
fermentation  of  carbohydrates  (milk  sugar),  has  not  been  definitely 
show^l  to  be  a  normal  constituent,  and  indeed  some  authorities  con- 
sider its  presence  in  the  stomach  as  pathological. 

Of  course,  there  is  a  possibility  of  other  acids  being  formed  in  the 
stomach,  for  example,  by  the  action  of  bacteria  on  food;  but,  accord- 
ing to  our  present  knowledge,  the  hydrochloric  acid  alone  is  of  real 
physiologic  importance.  The  ingested  milk  excites  the  secretion  of 
hydrochloric  acid,^  which  then  combines  with  the  proteins  of  the  food. 

This  occurs  in  the  healthy  breast-fed  infant  in  one  and  a  quarter  to 
two  hoilrs  after  nursing,  in  the  baby  fed  on  diluted  cow's  milk  it  takes 
not  less  than  two  to  two  and  a  half  hours,  while  with  whole  milk  the 
process  is  still  longer  delayed.  Free  hydrochloric  acid  undoubtedly 
exerts  an  antiseptic,  and,  if  sufficiently  concentrated,  even  a  bactericidal 
power.- 

Although  not  of  great  importance  this  power  is  sufficient  to  add 
one  more  to  the  many  advantages  of  breast-feeding.  Inasmuch  as 
mother's  milk  requires  less  acid  for  combination,  one-half  to  one-third 
of  that  of  cow's  milk,  the  amount  of  free  hydrochloric  acid  normally 
present  is  sufficient  as  a  bactericidal  and,  as  is  sometimes  claimed, 
also  a  detoxicating  agent. 

The  extent  to  which  pepsin  combined  with  hydrochloric  acid  assists 
in  protein  digestion  depends  upon  the  consistency  and  the  character 
of  the  food,  and  the  length  of  time  it  is  retained  in  the  infant's  stomach. 
Although  some  of  the  protein  is,  no  doubt,  acted  upon  and  partially 
peptonized,  the  bulk  of  it  in  all  probability  passes  almost  unchanged 
in  the  chyme  into  the  duodenum  together  with  primary  and  secondary 
proteoses  and  even  some  peptone.^ 

As  all  gastric  processes  are  merely  preliminary  to,  and  important 
for,  subsequent  digestion,  so  the  true  value  of  peptic  action  lies  in  its 
combination  with  trypsin.  This  enzyme  is  said  to  split  proteins  which 
have  been  submitted  to  the  action  of  pepsin  and  hydrochloric  acid  in 
a  way  different  from  that  which  takes  place  with  food  not  so  prepared. 
The  fact  that  a  low  temperature  retards  the  action  of  pepsin  shows  the 
importance  of  giving  food  at  a  proper  temperature,  preferablv  from 
100°  to  105°  F. 

Wherever  proteolytic  enzymes  may  be  found  in  the  body  there  is 
evidence  of  a  milk-curdling  function;  therefore  the  analogy  has  been 
dra^Ti  that  curdling  in  the  stomach  is  said  to  represent  an  action  of 
pepsin  itself,  and  is  not  due  to  a  specific  ferment.  However,  the  con- 
sensus of  opinion  attributes  the  coagulation  of  milk  in  the'  infant's 

1  A  weak  infusion  of  tea  and  albumin  water  produces  little  secretion  of  hydrochloric 
acid. 

2  Free  HCl  0.132  to  0.158  inhibits  growth  of  typhoid  bacilli;  free  HCl  0.185  kills  growth 
of  typhoid  bacilli;  free  HCl  0.08  inhibits  growth  of  cholera  baciUi;  free  HCl  0.10  kills 
growth  of  cholera  bacilli. 

^  The  latter  may,  however,  result  from  the  action  of  bacteria  in  the  stomach. 


GASTRIC  DIGESTION  189 

stomach  to  a  ferment  variously  called  remiet,  lab-ferment,  chymosin, 
rennins  or  pexin.^  It  is  supposed  to  be  present  in  the  glands  as  pro- 
rennin,  which  under  the  influence  of  acids  is  converted  into  rennin. 
This  acts  upon  the  casein  of  milk,  producing  soluble  paracasein,  which 
in  its  turn  reacts  with  the  soluble  calcium  phosphates  of  milk.  As 
a  result  the  insoluble  salt,  calcium-paracasein,  is  precipitated  in  the 
form  of  curds,  which  differ  considerably  in  the  breast-fed  and  in  the 
artificially-fed  baby. 

Undiluted  cow's  milk  is  said  to  curdle  in  rather  compact  masses 
containing  much  fat  entangled  in  their  meshes,  and  making  it  less 
digestible;  in  fact,  large  coagula  are  still  to  be  found  in  the  infant's 
stomach  half  an  hour  after  feeding.  Barley,  oatmeal,  rice,  or  arrow- 
root-water added  to  the  food  are  said  to  cause  curds  with  finer  flocculi 
and  thus  to  facilitate  digestion. 

Mother's  milk,  on  the  contrary,  coagulates  quite  imperfectly  and 
in  fine  flakes,  enclosing  only  a  little  fat.  Half  an  hour  after  nursing, 
the  gastric  contents  of  a  breast-fed  baby  are  seen  to  be  a  homogeneous 
mass  which  can  be  more  easily  acted  upon  by  the  digestive  juices  than 
the  dense  coagula  of  cow's  milk.  As  regards  the  coagulation  time, 
mother's  milk  is  almost  neutral,  and  coagulates  only  after  its  alkalinity 
has  been  sufficiently  reduced;  this  requires  about  one-half  to  three- 
quarters  of  an  hour,  while  cow's  milk,  being  acid  from  the  beginning, 
curdles  much  earlier. 

Rennet  coagulation  does  not  invariably  take  place,  nor  is  it  always 
complete,  but  is  influenced  by  the  composition,  the  dilution,  and  the 
temperature  of  the  milk,  as  well  as  by  the  presence  in  the  stomach  of 
clots  from  previous  feedings.  Curdling  is  hastened  by  warmth,  and 
occurs  most  promptly  at  106°  to  108°  F.  with  the  addition  of  an  inert 
foreign  matter,  such  as  starch,  etc.,  and  by  the  presence  of  acids,  as 
well  as  of  certain  acid  salts.  It  is  retarded  when  the  amount  of  soluble 
calcium  salts  is  relatively  decreased,  as  in  diluted  or  heated  milk,  and 
when  alkalies  or  alkaline  salts,  such  as  sodium  chloride  or  lime  water, 
are  added  to  the  milk. 

No  coagulation  at  all  takes  place  with  rennet  when  the  soluble 
calcium  salts  are  completely  removed,  and  since  boiling  the  milk 
decreases  their  amount  considerably  it  must  also  materially  aftect 
the  curdling  process.  The  action  of  rennin  is  limited  to  coagulation. 
The  digestion  of  the  curd  is  carried  on  to  a  small  extent  b\'  the  com- 
bined action  of  pepsin  and  hydrochloric  acid,  and  is  practically  com- 
pleted by  trypsin  with  the  formation  of  proteoses,  peptones,  peptids 
and  amino-acids  as  in  other  proteins. 

The  formation  of  curds  seems  to  be  the  effort  of  Nature  to  throw  part 
of  the  burden  of  protein  digestion  upon  the  stomach  by  delaymg  the 
passage  of  the  food  into  the  duodenum.  This  function  of  digestion 
should  therefore  be  encouraged,  as  it  probably  influences  the  muscular 
development  of  the  organ  to  a  considerable  degree. 

'  Casein  is  also  precipitated  from  milk  by  an  excess  of  acid  as  is  seen  in  sour  milk 
(lactic  acid.) 


190  NORMAL  DIGESTION 

The  duration  of  gastric  digestion  varies  with  the  age  and  the 
development  of  the  child,  as  well  as  with  the  quantity  and  the  quality 
of  the  food  taken.  At  one  month  the  stomach  of  a  healthy  breast-fed 
infant  ought  to  be  empty  in  from  one  to  one  and  a  half  hours  after 
nursing,  and  in  about  two  hours  up  to  the  eight  month;  cow's  milk 
requires  one-half  to  one  hour  longer. 

During  the  first  mouths  the  gastric  contents  pass  with  comparative 
rapidity  into  the  duodenum;  but,  as  the  stomach  increases  in  size  and 
larger  meals  are  taken,  the  food  remains  longer  wdthin  it.  All  fluids 
except  alcohol,  which  is  only  partially  absorbed,  begin  to  leave  the 
stomach  very  soon  after  a  meal,  and  a  considerable  amount  passes 
the  pylorus  during  the  first  half  hour.  Proteins  in  various  stages  of 
digestion  follow,  while  the  fats  are  ejected  last  of  all.  The  higher  the 
proportion  of  fats,  the  longer  is  the  food  retained  in  the  stomach  and 
the  smaller  is  the  amount  of  gastric  juice  secreted. 

Absorption  in  the  Stomach. — Absorption  does  not  take  place  readily 
in  the  stomach,  for  at  least  80  per  cent,  of  it  occurs  in  the  small  intes- 
tine; it  may,  however,  be  somewhat  increased  by  the  ingestion  of 
alcohol  and  certain  condiments.  Water,  when  ingested  alone,  is  prac- 
tically not  taken  up  at  all,  but  quickly  passes  on  into  the  intestines. 

Investigations  concerning  soluble  salts  are  still  incomplete,  but  it 
seems  certain  that  they  are  not  absorbed,  at  least  not  to  any  extent, 
until  they  reach  a  certam  definite  concentration.  Peptones,  peptids, 
and  amino  bodies  are  present  only  in  minute  amounts,  but  they  can 
be  and  are  absorbed,  especially  when  in  highly  concentrated  solutions. 
Fats  are  liquefied,  partly  emulsified,  and  perhaps  to  a  small  extent 
split  up,  but  their  intestinal  digestion  only  is  of  importance.  A  small 
proportion  of  sugar  is,  no  doubt,  also  absorbed  by  the  gastric  mucous 
membrane.  • 

In  summarizing,  w^e  may  say  that  very  little  absorption  takes  place 
from  the  stomach  directly:  a  certain  proportion  of  sugar  and  of  salts 
and  a  small  amount  of  nitrogenous  material  are  absorbed,  but  prac- 
tically no  water  and  no  fat. 

ANATOMICAL   AND  PHYSIOLOGICAL   PECULIARITIES    OF 
THE   INTESTINES. 

In  infants  the  intestinal  tract,  which  develops  from  a  mere  loop 
loosely  attached  to  the  posterior  abdominal  wall,  and  which  is  still 
in  the  formative  stage  after  birth,  is  found  to  be  less  fixed  than  in 
adult  life.  Its  elastic  tissue  is  only  slightly  developed,  the  musculature 
is  thinner  and  weaker,  and  there  is  relatively  less  difference  between 
the  diameters  of  the  large  and  the  small  intestines.  These  peculiarities 
explain  the  ease  with  which  the  bowels  become  distended,  and  the 
pronounced  tendenc\^  to  constipation,  colic,  and,  last  and  most  impor- 
tant, to  intussusception.  ■ 

The  intestinal  villi  are  well  developed;  Peyer's  patches  are  found 


PECULIARITIES  OF  INTESTINES  191 

very  earl}%  while  Brunner's  glands  are  said  to  be  less  abundant  than 
in  adults.  The  small  intestine  is,  on  an  average,  about  nine  feet  long 
at  birth,  and  this  length  increases  diu-ing  the  first  two  months  by 
about  four  feet,  making  it  relatively  longer  than  in  the  adult.  The 
length,  however,  may  vary  greatly,  depending  partly  upon  the  quan- 
tity and  the  kind  of  food  taken.  This  is  illustrated  by  the  fact  that 
among  the  poorer  classes  in  Russia,  who  of  necessity  live  almost 
exclusively  upon  vegetables,  the  intestines  are  found  to  be  considerably 
longer  than  among  other  people. 

At  birth  the  length  of  the  large  intestine  averages  about  one  foot, 
ten  inches,  which  is  about  the  height  of  the  body.  The  sigmoid 
flexure  is  situated  higher  than  in  the  adult,  only  one  or  two  of  its 
loops  curving  dowii  into  the  pelvis;  it  is  usually  half  the  length  of  the 
large  intestine.  The  colon,  however,  grows  more  rapidly,  so  that  at 
the  end  of  the  fourth  month  it  has  about  reached  adult  proportions, 
its  relatively  broad  mesentery  allowing  full  displacement.  The  cecum 
also  occupies  a  higher  and  more  median  position  than  in  the  adult 
and  is  very  mobile.  The  ascending  colon  is  very  short,  and  practically 
free,  as  a  relatively  large  part  of  it  is  invested  with  peritoneum.  The 
descending  colon  often  has  no  mesentery;  the  length  of  the  appendix 
is  variable,  and  its  position  most  uncertain. 

The  size  of  the  pancreas  at  birth  is  still  a  matter  of  discussion. 
It  shows  no  special  anatomical  features;  its  secretion  is  alkaline  in 
reaction,  and  is  stimulated  as  acids  come  into  contact  with  the  duodenal 
mucous  membrane.  It  begins  to  flow  very  soon  after  food  has  entered 
the  stomach,  and  reaches  its  maximum  in  from  tw^o  to  four  hours. 
The  amylolytic  enzyme  (pancreatic  amylase)  acts  similarly  to  ptyalin 
(salivary  amylase),  but  both  its  amount  and  its  activity  are  said  to 
be  limited  at  first;  its  function  seems  fairly  well  established  in  the 
second  half  of  the  first  year,  and  in  an  infant  of  six  months  it  can 
safely  be  called  upon  for  the  digestion  of  moderate  quantities  of 
starch. 

In  the  early  months  of  life  the  power  of  pancreatic  lipase  (steapsin) 
seems  to  be  only  slight,  but  it  increases  gradually,  and  reaches  its 
full  development  toward  the  end  of  the  first  year.  This  ferment  does 
not  act  rapidly  unless  aided  by  bile,  but  it  emulsifies,  saponifies,  and 
finally  splits  the  fats  into  glycerin  and  fatty  acids,  thus  fitting  them 
for  absorption  by  the  intestinal  epithelium.  By  the  action  of  the 
same  en:5yme,  they  are  probably  recombined  to  form  neutral  fats 
which  are  used  in  intermediate  metabolism.  A  milk-curdling  ferment 
has  been  described. 

Trypsin  like  pepsin  causes  hydrolytic  cleavage  of  proteins,  but  its 
effects  are  more  rapid  and  more  powerful,  and  it  requires  an  alkaline 
medium.  The  act^ial  products  formed  depend  to  some  extent  upon 
the  length  of  time  and  the  special  conditions  under  which  trypsin 
acts;  I.  e.,  proteins  are  said  to  be  more  rapidly  and  more  completely- 
broken  up  when  they  have  been  previously  acted  upon  by  pepsin. 


192  NORMAL  DIGESTION 

Trypsin  attacks  the  protein  molecnles  and  apparently  breaks  them 
up  into  their  end-products — amino-aeids.  Such  peptones,  proteoses 
or  peptids  as  may  have  escaped  its  final  action  are  acted  upon  by  the 
erepsin  of  the  succus  entericus  before  reaching  the  blood. 

Thus  the  proteins  are  almost  completely  disposed  of  under  normal 
conditions  and  the  nitrogenous  substances  which  are  fomid  in  the 
feces  of  a  normal  infant  are  principally  mucus,  bacterial  residues  of 
secretions,  and  epithelial  cells. 

In  disease  of  the  intestine  the  pancreatic  juice  seems  to  lose  its 
proteolytic  and  some  of  its  fat-digesting  properties,  while  its  diastatic 
function  is  said  to  be  less  disturbed. 

The  liver  is  proportionately  large  in  infancy  and  childhood,  being 
about  one-eighteenth  of  the  entire  body  weight  as  compared  with 
the  adult  proportion  of  one-thirtieth;  its  lower  border  can  normally 
be  palpated  one-half  to  one  inch  below  the  costal  margin  in  the  mam- 
mary line.  This  relatively  large  size  and  weight  indicate  that  it  per- 
forms a  very  important  function  and  that  it  is  well  adapted  to  the 
great  metabolic  activity  of  this  period  of  life. 

It  may  not  be  out  of  place  to  revert  to  the  fact  that  all  material 
coming  from  the  intestines  by  way  of  the  blood  must  pass  tlu-ough 
the  great  hepatic  filter.  While  it  has  been  definitely  proven  that 
the  glycogenic  function,  the  formation  of  urea  from  ammonia,  and 
the  secretion  of  bile  exist  in  the  newborn  babe,  it  seems  that  the 
hepatic  efficiency  for  destroying  poisons  is  not  thoroughly  established 
in  early  infanc^^ 

The  secretory  function  of  the  liver  is  developed  as  early  as  the  third 
month  of  intra-uterine  life,  when  both  bile  salts  and  pigments  find 
their  way  into  the  intestine.  At  birth  they  are  evidently  in  the 
meconium.  The  bile,  relatively  abundant  in  infanis,  presents  no 
essential  difference  in  its  action  from  that  of  the  adult.  Some  ^v^iters 
believe  that  its  composition  is  deficient  in  organic  salts,  and  also  that 
it  contains  a  smaller  percentage  of  cholestrol,  lecithin,  glycocholic 
and  taurocholic  acids. 

Bile  salts  are  believed  to  have  the  property  of  aiding  in  the  emul- 
sification  and  the  cleavage  of  fats.  The  small  proportion  of  bile  salts 
present  during  infancy  accounts  for  the  feeble  antiseptic  power  of  the 
bile,  and  for  the  consequent  fermentation  of  the  intestinal  contents, 
as  well  as  for  the  incomplete  absorption  of  very  fatty  foods.  Perhaps 
the  resulting  fatty  acids  irritate  the  intestinal  mucous  membrane, 
and  thus  disturb  digestion. 

Succus  Entericus. — The  secretions  from  the  follicles  of  Lieberkiihn 
and  from  Brunner's  glands  are  alkaline,  and  are  stimulated  by  the 
ingested  food,  which  is  then  subjected  to  their  chemical  action.  The 
following  enzymes  have  been  isolated  from  the  mucous  membrane 
of  the  walls  of  the  small  intestine : 

1.  Enterokinase,  which  converts  trypsinogen  into  trypsin. 

2,  Erepsin,  which  digests  products  of  protein  digestion  that  may 


ABSORPTION  IN  THE  INTESTINES  193 

ha\'e  escaped  the  action  of  trypsin;  e.  g.,  proteoses,  peptones  and  pep- 
tids;  it  also  digests  casein  of  milk. 

3.  Inverting  ferments.  These  are  as  follows:  Maltase,  which  con- 
verts maltose  into  dextrose.  Invertase  or  sucrase,  which  converts 
cane  sugar  into  dextrose  and  levulose.  Lactase,  which  converts 
milk  sugar  into  dextrose  and  galactose. 

The  intestinal  canal  of  the  newborn  infant  does  not  differ  so  much 
anatomically  as  it  does  functionally  from  that  of  later  life.  The 
gastric  contents,  after  having  been  propelled  through  the  pylorus 
into  the  duodenum,  are  mixed  with,  and  subjected  to  the  combined 
action  of,  the  bile  and  the  pancreatic  and  intestinal  juices.  It  is  in 
the  small  intestine  that  the  most  profound  changes  occur,  and  the 
products  of  digestion  are  mainly  absorbed.  By  the  time  the  food 
arrives  at  the  ileocecal  valve  these  processes  are  practically  complete. 

Absorption  in  the  Intestines. —  Chyme,  or  the  stomach  contents 
passed  into  the  infant's  duodenum,  is  chiefly  composed  of  watery 
elements  containing  sugars,  salts,  etc.,  in  solution.  The  proteins 
are  partly  unchanged  (casein  coagula),  and  partly  appear  in  the  form 
of  acid  metaprotein,  proteoses,  and  peptones.  Fats  pass  into  the 
intestines  suspended  in  fluids  or  entrapped  in  the  meshes  of  casein 
curds.  The  acidity  of  the  chyme,  due  chiefly  to  HCl,  is  neutralized 
by  the  pancreatic  and  intestinal  juices  and  the  bile. 

About  80  per  cent,  of  all  absorption  takes  place  in  the  small  intes- 
tine, which  accounts  for  the  fact  that  disturbances  in  this  part  of  the 
digestive  tract,  with  their  concomitant  diarrhea  and  frequent  watery 
passages,  are  followed  by  extremely  rapid  wasting  and  exhaustion. 
Proteins  are  supposed  to  be  absorbed  in  the  form  of  amino-acids, 
and  in  healthy  breast-fed  infants  this  absorption  takes  place  almost 
entirely  in  the  upper  part  of  the  small  intestine;  only  traces  of  protein 
are  found  in  the  lower  ileum.  The  reaction  of  the  upper  part  of  the 
gut  is  slightly  acid.  In  artificially  fed  babies  the  digestion  and  the 
solution  of  casein  are  less  complete  in  the  duodenum,  and  the  reaction 
is  distinctly  acid. 

Pancreatic  lipase  (steapsin),  assisted  by  bile,  splits  fats  into  fatty 
acids  and  glycerol  and  also  saponifies  and  emulsifies  them.  In  these 
forms  they  are  readily  taken  up  by  the  intestinal  villi,  but  become 
converted  into  neutral  fats  during  their  passage  through  the  mucous 
membrane.  Fats  are  not  completely  digested  and  absorbed  in  the 
intestines  of  infants,  considerable  being  excreted  in  the  feces  as  neutral 
fats  and  fatty  acids. 

The  sugars  are  taken  up  as  dextrose,  which  is  the  most  readily 
absorbed  monosaccharide.  Galactose  and  levulose  must  undergo  a 
further  process  of  inversion  to  dextrose  before  they  can  be  taken  up. 
It  would  thus  apptiar  that  maltose,  which  splits  into  two  molecules 
of  dextrose,  may  be  absorbed  more  readily  than  either  lactose  or 
saccharose.  There  is  still  a  difference  of  opinion  as  to  whether  pan- 
creatic amylase  (amylopsin)  is  active  in  early  mfancy;  later  on  it 
can  and  does  convert  starch  into  maltose,  as  shown  on  next  page. 
13 


194  NORMAL  DIGESTION 


Starch 

I 
Soluble  starch 


Erythrodextrin  Maltose 


a-Achro6dextrin  Maltose 


/3-Achro6dextrin  Maltose 


I 1 

1  I 

T-Achroodextrin  Maltose 

I  I  ■  - 

L 1 

Maltose 

In  the  large  intestine  little  else  but  water  is  absorbed,  so  that  an 
infection  of  the  colon  alone  produces  comparatively  little  wasting. 
Fat  absorption  is  slight,  while  sugars,  salts,  and  peptones  may  be 
absorbed  with  moderate  facility;  therefore,  in  rectal  feeding  the  food 
should  be  thoroughly  predigested. 

The  stools  of  infants  and  of  children  are  a  delicate  index  of  the 
state  of  the  digestive  functions,  and  a  careful  exammation  of  the 
feces  in  conjunction  with  other  clinical  observations  will  give  us  a 
fair  idea  as  to  whether  the  food  is  being  digested  and  assimilated. 
In  order  to  detect  abnormal  conditions  it  is  necessary  to  be  thoroughly 
familiar  with  the  characteristics  of  normal  evacuations.  Normal, 
of  course,  does  not  mean  uniform;  it  is  well  knoTMi  that  even  in  a 
perfectly  healthy  infant  the  stools  may  at  times  vary  in  color  and 
consistency,  and  may  even  contain  coarse  white  particles.  This  is 
not  astonishing  when  we  consider  that  even  such  an  ideal  food  as 
mother's  milk  is  not  always  uniform  in  composition,  especially  in  its 
percentage  of  fat. 

During  the  first  two  or  three  days  after  birth  the  infant  has  about 
four  to  six  passages  of  semisolid,  dark,  bro^\Tiish-green  meconium.^ 
These  may  continue  for  a  week,  but  they  usually  begin  to  change  in 
character  on  the  third  or  fourth  day,  and  soon  assume  the  usual  appear- 
ance of  the  healthy  feces  of  the  breast-fed  infant.  These  discharges 
contain  mucus,  fats,  epithelial  debris,  and  a  small  portion' of  albuminous 
matter,  their  normal  amount  varying  between  two  and  three  ounces 
per  day.  They  are  golden-yellow  in  color,  owing  to  the  presence  of 
bilirubin,  are  homogeneous,  of  butter-like  consistency,  with  an  acid 
reaction,  and  a  slightly  acid  odor,  probably  due  to  lactic  and  fatty 
acids.     The  small  whitish   curd   particles   already  referred  to — the 

1  Meconium  is  composed  of  intestinal  mucus,  bile,  vernix  caseosa,  epithelial  cells, 
hairs,  fat  globules,  and  cholesterol  crystals. 


BACTERIA   IN   THE  INTESTINES  195 

so-called  milk  granules  of  Uffelmann — are  not  albumin,  but  fat  crys- 
tals and  zooglea  of  bacteria. 

Normal  milk  feces  contain  about  85  per  cent,  of  water  and  15  per 
cent,  of  solids,  mostly  fats.  Hydrogen  and  carbon  dioxide  are  the 
only  gas  constituents;  H2S  and  marsh  gas  are  never  present.  Protein 
is  almost  entirely  absent,  the  minute  quantities  which  may  have 
escaped  solution  and  digestion  being  transformed  by  the  intestinal 
bacteria  into  indol,  skatol,  phenol,  and  ammonia.^  Fats  occur  in 
the  form  of  fatty  acids,  soaps,  and  neutral  fats,  and  form  from  10  to 
20  per  cent,  of  the  dry  residue  of  milk  feces.  Sugar  is  absent,  but  its 
derivative,  lactic  acid,  may  be  encountered  in  small  amounts,  while 
starch  may  appear  unchanged  in  the  stools.  The  inorganic  salts  are 
chiefly  represented  by  the  calcium  salts,  and  the  biliary  elements  by 
hydrobilirubin,  unchanged  bilirubin,  and  cholesterol. 

In  addition  to  these  the  feces  contain  much  mucus,  immense  num- 
bers of  bacteria,  and  various  products  of  bacterial  germination.  The 
stools  number  from  three  to  six  per  diem  during  the  first  month, 
afterward  decreasing  to  from  one  to  three,  and  later  on  to  one  daily 
movement.  The  stools  of  the  bottle-fed  baby  are  larger  in  bulk  and 
contain  less  water  than  those  of  the  breast-fed  infant;  they  may  also 
be  more  frequent,  as  many  as  four  or  even  six  being  compatible  with 
health  as  long  as  their  consistency  and  color  remain  normal.  The 
number  of  stools  is  merely  an  indication  of  the  amount  of  intestinal 
residue,  and  not  of  disease. 

In  a  baby  fed  on  cow's  milk  that  has  been  perfectly  digested,  the 
feces  may  closely  resemble  those  of  the  breast-fed  child,  but  usually 
they  are  firmer,  paler,  and  putty-like,  with  a  neutral  or  alkaline  reac- 
tion, and  slightly  offensive  odor.  Infants  fed  on  malted  or  farinaceous 
foods  have  more  or  less  dry  and  broken-up  movements,  yellowish- 
brown  in  color,  and  slightly  alkaline,  with  a  malt-like  odor. 

The  stools  are  never  fulh'  formed  until  a  mixed  diet  is  given.  The 
peculiar  character  of  milk  stools  •  then  disappears,  the  feces  become 
darker  and  emit  the  adult  odor,  but  are  softer  than  the  latter.  The 
reaction  of  the  fecal  discharges  is  still  a  matter  of  discussion.  As  a 
rule,  it  is  acid  in  the  breast-fed  baby,  while  in  the  bottle-fed  baby  it 
is  said  to  be  feebly  alkaline  or  neutral,  provided  the  cow's  milk  is  well 
digested;  but  if  the  fat  percentage  of  the  milk  is  too  high  or  if  more 
carbohydrates  are  given  than  can  be  digested,  the  reaction  becomes 
acid. 

Bacteria. — Experiments  and  investigations  concerning  the  bacteria 
which  inhabit  the  intestines  are  as  yet  incomplete,  and  probably  will 
be  so  for  some  years  to  come..  After  all,  what  would  be  gained  if  we 
(fould  really  distinguish  and  study  each  variety  separately?  Consider- 
ing that  every  speMes  existing  in  the  intestines  is  influenced  in  its 
development  and  its  function  by  other  varieties  and  groups  actually 
present,  or  temporarily  predominating,  it  seems  more  important  for 

1  The  nitrogen  content  in  these  feces  is  derived  chiefly  from  the  intestinal  secretion 
and  from  the  bodies  of  bacteria, 


196  NORMAL  DIGESTION 

practical  purposes  to  study  the  chemical  changes  produced  in  intes- 
tinal secretions  and  in  the  ingested  food  by  the  combined  action  of 
all  the  microorganisms  living  in  the  intestines. 

What  changes  are  known  to  be  bacterial  in  origin?  In  the  normal 
breast-fed  infant  the  intestinal  flora  are  almost  constant.  To  begin 
with,  bacteria  are  absent  from  the  gastro-intestinal  tract  at  birth, 
but  twenty-four  hours  later  they  have  effected  an  entrance  through 
the  mouth  and  rectum.  When  breast  milk  is  exclusively  used  the 
principal  organisms  present  are:  Bacillus  aerogenes,  Bacillus  coli 
communis,  and  Bacillus  bifidus,  although  as  many  as  19  different  kinds 
have  been  isolated  from  the  stools  of  healthy  nurslings. 

Their  number  and  distribution  vary  considerably  in  different  parts 
of  the  gut,  relatively  few  being  found  in  the  small  intestine,  while 
they  flourish  in  the  cecum  and  the  colon.  In  the  healthy  baby  they 
serve  a  useful  purpose  by  aiding  in  the  digestion  of  the  food  elements.^ 
Their  most  important  role,  however,  seems  to  consist  in  producing 
the  acid  fermentation  which  prevails  in  the  intestines  of  the  breast-fed 
infant.  This  lessens  the  development  of  other  harmful  microbes,^ 
and  reduces  their  action  considerably. 

As  carbohydrates  favor  the  development  of  some  of  these  normally- 
present,  acid-producing  bacteria,  the  putrefactive  processes  can  be 
modified,  and  to  some  extent  controlled,  by  means  of  a  diet  rich  in 
carbohydrates  and  relatively  poor  in  proteins.  Aside  from  the  bene- 
ficial effect  of  partial  starvation  induced  by  such  a  diet,  it  in  a  measure 
explains  the  value  of  carbohydrate  food  in  the  early  treatment  of  intes- 
tinal indigestion  and  also  the  temporary  success  which  sometimes 
follows  the  use  of  condensed  milk  or  similar  foods. 

The  great  danger  of  nutritional  disorders  in  infancy  and  childhood 
hardly  needs  emphasis.  By  lowering  the  power  of 'resistance  to 
disease,  they  directly  or  indirectly  cause  more  deaths  in  this  early 
period  of  life  than  all  other  illnesses  combined.  Disturbances  of 
nutrition  do  not  involve  merely  the  processes  of  digestion  and  absorp- 
tion in  the  gastro-intestinal  canal,  but  also  the  very  important  func- 
tions of  assimilation  and  disassimilation,  known  as  intermediary 
metabolism. 

A  derangement  of  these  processes  not  only  hinders  the  normal 
function,  but  also  retards  the  development  of  the  immature  body. 
The  proper  appreciation  of  this  fact  will  enable  us  to  realize  the 
great  importance  of  this  subject,  and  will  lead  to  the  selection  of  the 
method  of  feeding  most  suited  to  the  individual  case.  As  the  process 
of  metabolism  in  older  children  progressively  becomes  like  that  of 
the  adult  we  may  confine  our  attention  to  the  differences  observed  in 
the  infant. 

To  begin  with,  it  must  be  acknowledged  that  the  number  of  ascer- 
tained facts  is  small  and  that  their  clinical  significance  often  seems 

'  Experiments  have  demonstrated  that  newborn  animals,  fed  with  sterilized  food, 
remained  decidedly  backward;  some  of  them  could  not  even  be  kept  alive. 

2  J^or  instance,  putrefactive  bacteria,  which  thrive  on  the  proteins  of  boiled  milk. 


GASTRIC  AND  INTESTINAL  SECRETIONS  1^7 

ohscure.  What  then  are  the  abnormalities  known  to  occur  under 
])athological  conrlitions  within  the  digestive  tract?  As  to  the  study 
of  the  changes  in  the  gastric  secretions,  the  stomach  tube  has  con- 
siderably facilitated  research  in  this  direction.  In  almost  all  of  the 
constitutional  diseases  of  infancy,  gastro-intestinal  as  well  as  febrile, 
the  secretion  of  hydrochloric  acid  is  greatly  diminished,  so  much  so 
that  in  many  cases  it  is  not  present  at  all  in  the  free  state.  This 
entails  more  or  less  complete  loss  of  the  antiseptic  action  of  the 
normally  present  free  hydrochloric  acid. 

On  the  other  hand,  as  regards  therapeutics,  it  clearly  demonstrates 
the  necessity  of  longer  intervals  between  feedings  for  the  sick  child, 
especially  when  cow's  milk  is  taken,  since  the  latter  requires  about 
30  per  cent,  more  acid  than  does  mother's  milk.  Hyperchlorhydria 
is  found  in  rare  conditions,  such  as  congenital  pyloric  stenosis.  This, 
however,  is  due  to  overproduction  as  well  as  to  accumulation,  favored 
by  delayed  evacuation  of  the  gastric  contents.  Since  the  salivary 
amylase  (ptyalin)  and  the  gastric  ferments,  rennin  and  pepsin,  are  all 
secreted  in  sufficient  quantity  in  sick  children,  it  is  evident  that  the 
administration  of  these  enzymes  by  mouth  would  not  prove  very 
beneficial  in  these  nutritional  disorders. 

As  for  the  other  secretions,  the  detoxicating  action  of  the  liver  in 
the  infant  has  not  been  definitely  proven,  but  there  is  good  reason  for 
accepting  the  statement  that  in  the  course  of  certain  diseases  the 
digestive  power  of  the  pancreatic  secretions,  and  especially  that  due 
to  trypsin  and  pancreatic  lipase  (steapsin)  may  be  diminished.  We 
know  that  the  power  of  digesting  starch  is  slight  during  the  first  few 
months  of  life;  but  as  yet  we  know  very  little  concerning  the  changes 
in  the  activity  of  the  intestinal  glands  during  illness,  although  duo- 
denal catheterization  will  no  doubt  aid  us  considerably  in  the  future 
in  gaining  a  clearer  insight  into  this  part  of  the  body  economy. 

In  basing  our  conclusions  upon  these  few  facts,  we  scarcely  feel 
justified  in  declaring  that  disorders  of  nutrition  are  identical  with  a 
disturbance  in  the  digestion  or  the  absorption  of  the  various  foodstuffs 
within  the  intestinal  canal.  On  the  contrary,  it  is  well  known  that, 
even  by  very  sick  children,  nitrogen  and  milk  sugar  are  very  well 
taken  up;  the  milk  sugar  is  absorbed  unchanged  only  in  exceptional 
cases,  and  then  appears  as  such  in  the  urine. 

As  regards  fats,  there  is  no  doubt  that  during  illness  a  considerable 
amount  passes  unutilized  through  the  intestinal  canal  to  be  excreted 
with  the  feces,  either  in  the  form  of  neutral  fats — true  fat  diarrhea, 
which  is  rare — or  as  soap-stools,  ?".  e.,  combined  with  alkalies.  Free 
fatty  acids  too  may  be  found  predominating  in  the  fecal  discharges, 
but  in  none  of  these  eventualities  has  the  loss  of  fat  been  demon- 
strated to  be  so  large  as  seriously  to  injure  nutrition. 

The  fi^w  data  which  we  possess  concerning  the  excretion  of  mineral 
salts  in  the  feces  show  that  these  bear  no  direct  relationship  to  any 
definite  disease.  Normally,  fermentation  predominates  in  the  intes- 
tines of  the  breast-fed  infant,  while  putrefaction  is  present  to  a  limited 


198  NORMAL   DIGESTION 

extent  in  the  Ijottle-Fed  l)a])y.  In  certain  pathological  conditions, 
however,  ])iitrefaction  occurs  with  l)oth  types  of  feeding,  its  presence 
being  confirmed  by  the  oft'ensi^'e  odor  of  the  feces  and  the  appearance 
of  indican  in  the  iirine.^ 

Raw  milk  does  not  putrefy  readily;  indeed,  its  milk  sugar  may 
under  favorable  circumstances  even  prevent  putrefaction;  it  is,  there- 
fore, probable  that  the  intestinal  secretions  themselves,  increased  by 
certain  disturbances,  furnish  the  material  for  putrefaction,  especially 
in  the  bottle-fed  baby.  This  process  is  also  aided  by  the  diminution 
or  the  complete  absence  of  free  HCl,  which  normally  acts  as  an  anti- 
septic. 

AMiether  or  not  the  products  of  putrefaction  can  directly  injure  the 
organism  is  not  definitel}'  known.  Since  assimilation  and  retention 
of  the  necessary  food-elements  are  essential  for  growth,  the  question 
arises,  to  what  extent  do  pathological  conditions  influence  these  nor- 
mal functions?  Again  we  must  confess  our  limitations  as  to  any  know- 
ledge on  the  subject.  There  is  no  doubt  that  a  certain  amount  of 
nitrogen  is  retained  under  practically  all  conditions,  even  when  a 
sick  infant  loses  in  weight,  and  it  necessarily  follows  that  at  such 
periods  other  foodstuffs,  especially  fats,  must  pass  through  the  body 
unutilized.  Very  often  the  fluctuations  in  the  weight  of  the  infant 
are  so  marked  within  short  periods  of  time  that  these  variations  can 
only  be  explained  by  a  pathological  change  in  the  watery  content 
of  the  body.  This  is  not  surprising  when  we  consider  that  more  than 
60  per  cent,  of  the  total  food  assimilated  consists  of  water. 

Phosphates  originating  from  milk  are  usually  well  retained,  even 
by  a  sick  baby,  while  chlorides  are  apt  to  vary  with  alterations  in 
the  w^ater  content  of  the  whole  organism,  or  vice  versa.  lAn  abnormal 
loss  of  lime  may  be  a  causal  factor  in  defective  ossification,  as  seen 
in  rickets,  and  may,  perhaps,  play  a  role  in  the  etiology  of  tetany, 
an  affection  in  which  the  brain  has  been  found  to  be  exceptionally 
deficient  in  lime  salts. 

The  processes  of  disassimilation  in  the  sick  infant  presumably  differ 
from  those  in  a  healthy  baby.  Excessive  oxidation  is  supposed  to 
interfere  w^ith  normal  metabolism  in  atrophic  conditions,  where  an 
infant  w^ith  an  excellent  appetite  loses  weight  instead  of  gaining. 
Certain  disturbances  durmg  infancy,  presumably  intestinal  in  origin, 
but  more  often  during  childhood,  lead  to  the  excretion  of  acetone  bodies 
through  the  lungs  instead  of  in  the  mine,  as  in  adult  life.  The  con- 
comitant cyclic  vomiting  and  fever,  so  frequent  in  older  children,  are 
often  associated  wdth  the  presence  of  considerable  acetone  in  the 
urine. 

Keller,  of  Breslau,  has  demonstrated  some  interesting  and  practical 
facts  for  the  diet  of  sick  babies  concerning  the  metabolism  of  mineral 
salts.  It  has  been  noted  that  the  urine  of  infants  suffering  from  cer- 
tain nutritional  disorders  often  contains^  a  relatively  large  amount 

1  Indican  is  absent  in  the  urine  of  healthy  breast-fed  babies,  bnt  a  small  amount  is 
present  in  that  of  healthy  bottle-fed  babies. 


FAT  INDIGESTION  199 

of  aininoiiia.  Keller  and  his  school  claim  that  an  excess  of  fat  in  the 
infant's'  food  combines  with  alkalies  in  the  intestines  and  forms  soaps 
which  are  excreted  in  the  feces.  The  alkalies  rec^nired  for  the  neu- 
tralization of  the  inorganic  acid  end-products  of  metabolism  are  thus 
prevented  from  reaching  their  destination,  and  fulfilling  their  pur- 
pose, and  Nature  provides  the  necessary  substitute  in  the  form  of 
ammonia  which  later  appears  in  the  urine. 

While  it  has  not  yet  been  definitely  proven,  it  seems  probable  that 
an  excessive  loss  of  alkalies  may  lead  to  actual  acidosis,  and  the 
injurious  consequences  of  overfeeding  with  one  food  constituent  are 
at  once  apparent.  The  same  investigators  have  by  analogy,  basing 
their  conclusions  upon  their  clinical  observations,  described  similar 
food  injuries  occasioned  by  diminished  tolerance  of  starch,  sugar, 
proteins,  and  of  whey  salts. 

Czerny  and  Keller  claim  that  the  ingestion  of  fats,  carbohydrates, 
proteins,  and  whe\^  salts  "beyond  the  point  of  tolerance"  produces 
distinct  symptoms  resulting  from  food  injuries,  which  concern  not 
only  the  digestion  and  absorption,  but  also  the  intermediary  metab- 
olism of  the  infant.  This  symptom-complex  is  of  great  clinical 
value,  inasmuch  as  its  recognition  may  obviate  the  prolonged  starva- 
tion so  frequent  in  chronic  and  acute  indigestion.  The  mere  with- 
drawal of  the  offending  constituent  from  the  food  is  sufficient  to 
inaugurate  improvement,  and  with  proper  care  will  insure  a  final  cure. 

It  must,  however,  be  admitted  that  these  symptom-groups  are 
not  always  clearly  defined.  For  instance,  in  the  same  individual 
there  may  be  shown  different  degrees  of  tolerance  for  more  than  one 
food  element.  Likewise,  in  a  given  case,  carbohydrates  may  be 
tolerated  only  when  the  food  contains  a  low  percentage  of  fats,  or 
fats  may  be  metabolized  when  the  carbohydrates  are  cut  down. 
Proteins  do  not  seem  to  aggravate  the  intolerance  for  either  fats  or 
carbohydrates,  but  protein  intolerance  is  aggravated  by  a  higher 
percentage  of  either  fat  or  carbohydrates  in  the  food. 

The  objection  has  been  made  that  these  subdivisions  are  too  sche- 
matic. Possibly  they  are;  but  they  have  the  great  advantage  of 
being  practical  and  simple;  for  a  correct  diagnosis  at  the  same  time 
quite  definitely  indicates  the  proper  remedy.  At  all  events,  they  seem 
to  be  a  step  forward  in  emancipating  us  from  the  one-sided  bacterio- 
logical viewpoint,  and,  though  only  a  stepping-stone  to  the  final  solu- 
tion of  the  complicated  problem  of  infant  feeding,  they  are  worthy 
of  consideration. 

Fat  Indigestion. — The  proper  amount  of  fat  in  an  infant's  diet  is 
necessary  for  the  production  of  teeth,  for  the  regulation  of  the  bowels, 
and  for  the  nourishing  and  building  up  of  the  bony  and  nervous 
systems.  Moreover,  there  exists  an  intimate  relationship  between 
fat  metabolism  and  the  resistance  of  the  child  to  infection.  It  follows, 
therefore,  that  a  baby^  may  suffer  more  or  less  from  malnutrition, 

'  This  differs  in  different  individuals  according  to  their  digestive  ability,  etc. 


200  NORMAL  DIGESTION 

anemia,  .lack  of  development,  and  decreased  power  of  resistance  to 
disease  (rickets)  either  because  of  too  little  fat  in  the  food  or  because 
of  its  inability  to  digest  and  assimilate  the  fat.  Fat  indigestion  is 
very  often  due  to  overfeeding  with  rich  milk  or  cream  mixtures ;  oils — 
olive  oil  and  cod  liver  oil — curiously  enough,  seem  to  create  less 
trouble. 

In  addition  to  the  ordinary  manifestations  of  indigestion,  an  excess 
of  fat  in  the  food  causes  a  more  or  less  distinct  group  of  symptoms, 
such  as  malnutrition,  coated  tongue,  fetid  breath,  and  gastric  dis- 
turbances, especially  sour  vomiting  soon  after  feeding.  The  child 
looks  pale,  its  complexion  is  muddy,  and  it  often  suffers  from  eczema 
and  intertrigo  of  the  buttocks. 

Constipation  is  the  rule  but  this  may  alternate  with  diarrhea.  The 
stools  sometimes  have  a  shiny,  oily  look  (fat  diarrhea)  with  a  butyric 
odor.  More  often  they  are  small,  fragmentary,  hard,  dry,  crumbly, 
and  grayish- white  in  color;  they  then  contain  a  large  amount  of 
insoluble  salts,  and  do  not  soften  even  under  the  influence  of  a  water 
enema.  Microscopic  examination  of  the  feces  reveals  an  excess  of 
neutral  fats,  fatty  acids,  and  soaps.  The  loose  stools  contain  small 
soft  curds,  somewhat  resembling  scrambled  egg. 

Colic  is  a  frequent  symptom,  but  it  is  usually  caused  by  overfeeding 
or  by  undigested  proteins.  The  urine  is  rather  irritating,  and  smells 
strongly  of  ammonia.  The  more  serious  fat  injuries,  however,  are 
uncommon  except  when  the  food  contains  an  excess  of  both  fats  and 
sugars.  The  fat  of  mother's  milk  contains  less  fatty  acids,^  and  is 
therefore  more  easily  digested.  This  in  a  measure  explains  why  an 
infant  can  assimilate  mother's  milk  with  its  4  per  cent,  of  fat,  while 
it  may  fail  to  digest  the  2  per  cent,  fat  in  cow's  milk,  and  also  why 
the  latter  with  its  excess  of  acids  may  be  readily  concerted  into 
diacetic  acid  and  acetone. 

Carbohydrates. — Sugars,  being  the  most  easily  digested  elements 
in  the  infant's  artificial  food,  are  liable  to  be  increased  at  the  expense 
of  the  fats  and  the  proteins.  Like  fats,  they  serve  as  fuel,  furnishing 
heat  and  supplying  energy  to  the  cells.  While  they  may  be  partially 
converted  into  fats,  and  temporarily  replace  these,  a  prolonged  sugar 
diet  will  lead  to  serious  disturbances. 

Most  physicians,  aware  of  the  excess  of  carbohydrates  in  many 
proprietary  foods  which  are  so  often  advertised  as  substitutes  for 
milk,  advise  against  their  use  except  in  certain  cases  where,  with 
the  proper  admixture  of  milk,  they  serve  a  useful  purpose.  By  chang- 
ing the  intestinal  flora  they  are  apt  to  create  fermentation,^  which, 
within  limits,  seems  necessary  for  the  proper  functionating,  of  the 
intestinal  processes  in  infants.  We  say  "within  limits,"  because  the 
products  of  excessive  acid  fermentation  may  irritate  the  mucous 
membrane,  and  thus  cause  purgation. 

1  Glycerides  of  butyric,  caproic,  caprylic,  and  myiistit!  acids. 

2  This  fermentation  cannot  always  be  produced  by  starch  alone,  but  sometimes  requires 
the  addition  of  sugar. 


PROTEIN  INDIGESTION  201 

Cereals,  such  as  barle}^  rice,  arrow-root,  etc.,  are  useful  even  before 
the  child  is  able  to  digest  them  perfectly,  since  they  mechanically 
facilitate  protein  digestion  by  preventing  the  formation  of  very  coarse 
casein  curds.  Some  infants,  it  is  true,  can  take  a  great  deal  of  carbo- 
hydrate food  with  apparent  impunity.  They  often  look  well  and 
sturdy,  and,  although  rather  fat,  they  have  a  good  color  and  tolerably 
firm  flesh.  The  stools  are  yellow  or  brown,  not  green,  and  are  often 
formed,  and  have  an  acid  reaction. 

Except  for  a  certain  amount  of  meteorism,  there  seems  to  be  noth- 
ing wrong  with  the  baby,  but  should  it  be  attacked  by  disease  it  shows 
very  little  power  of  resistance,  thus  confirming  the  every-day  experience 
of  the  temporary  character  of  the  apparently  good  results  of  artificial 
feeding  and  its  probable  ultimate  failure. 

As  a  rule,  however,  food  containing  an  excess  of  carbohydrates 
soon  leads  to  intolerance,  indigestion,  or  to  sugar  intoxication,  as 
indicated  by  loss  of  weight,  flabby  musculature,  colic,  nervousness, 
irritability,  urticaria,  and  even  fever. ^  The  stools  are  numerous, 
watery,  non-putrid,  light  green  in  color,  and  irritating  to  the  skin 
of  the  buttocks  on  account  of  their  acidity;  they  contain  no  curds 
and  are  passed  with  flatus.  Gas  formation  producing  tympanites, 
'vomiting,  and  regurgitation  of  sour  material  is  a  common  symptom. 

In  more  severe  cases  where  the  intolerance  has  been  aggravated  by 
prolonged  dietetic  errors,  lactose,  and  frequently  acetone  and  diacetic 
acid,  may  be  found  in  the  urine.  These  babies  become  thin,  delicate, 
anemic;  the  tongue  is  coated,  the  appetite  is  poor  or  capricious, 
and  they  suffer  from  constipation,  abdominal  distention,  and  severe 
constitutional  disturbance.  With  such  patients  sugar  intoxication  is 
commonly  associated  with  an  inability  to  metabolize  whey  salts. 

Treatment  consists  in  eliminating  the  latter  as  well  as  the  sugars 
from  the  diet  temporarily,  and  when  the  symptoms  have  subsided, 
a  different  sugar  in  proper  proportion  should  be  cautiously  added; 
maltose  and  dextrin  are  preferable,  because  they  are  not  apt  to  produce 
fermentation,  while  milk  sugar  is  prone  to  set  up  fever  and  diarrhea. 

Protein  Indigestion. — While  indigestion  of  proteins,  especially  the 
casein  of  cow's  milk,  does  not  seem  to  be  so  common  as  has  generally 
been  considered,  its  existence  cannot  be  altogether  denied.  It  certainly 
does  occur,  especially  with  foods  having  a  high  fat  content,  and  is 
accompanied  by  the  ordinary  symptoms  of  intestinal  disturbance, 
such  as  diarrhea,  constipation,  fever,  colic,  and  sometimes  even  severe 
nervous  manifestations. 

The  stools  in  these  cases  are  foul-smelling,  alkaline,  and  occasion- 
ally contain  curds,  which,  unlike  those  of  fat  indigestion,  are  usually 
hard,  tough,  and  not  friable.  They  are  frequently  oblong,  rounded 
or  bean-shaped,  and*vary  in  size  from  that  of  a  lentil  to  a  lima  bean, 
while  in  their  consistency  and  appearance  they  resemble  hard  American 

'  Sugar  fever  is  similar  to  salt  fever.  In  the  body  of  infants,  sugar  seems  to  act  much 
as  an  inorganic  salt;  being  loosely  combined  and  probably  stored  in  the  subcutaneous 
tissues,  it  favors  the  retention  of  water  in  the  system. 


202  NORMAL  DIGESTION 

cheese.  Tlie  curds  can  easily  be  picked  out  of  the  napkin  with  a  i)in, 
washed  and  shaken  about  in  water  without  being  broken,  and  when 
dropped  into  water  they  sink  to  the  botton. 

It  is  said  that  these  casein  curds  disappear  from  the  stools  if  a  diet 
of  boiled  and  diluted  milk  exclusively  is  given,  and  that  they  occur 
only  in  infants  fed  on  pasteurized  or  raw  milk  with  a  low  fat  per- 
centage. The  proteins  alone  supply  the  body  with  nitrogen,  and  no 
other  food  element  can  take  their  place,  consequently'  the  feeding  of 
proper  amount  of  proteins  is  of  primary  importance  during  early 
infancy — the  time  of  rapid  development. 

If,  for  therapeutic  purposes,  it  becomes  necessary  to  reduce  the 
amount  of  proteins  temporarily,  they  should  be  raised  to  the  normal 
proportion  as  soon  as  possible  in  order  to  prevent  anemia,  loss  of 
muscular  tone  and  power,  and  circulatory  disturbances.  A  food 
containing  too  little  of  both  proteins  and  fats  predisposes  to  constipa- 
tion and  probably  to  rachitis.  \Vhey  proteins  are  very  easily  digested 
and  rarely  cause  disturbance;  any  trouble  thej'  may  set  up  is  due  to 
their  whey  salts. 

For  many  years  attempts  have  been  made  to  classify  nutritional 
disturbances,  but  the  results  have  been  unsatisfactory,  the  grouping 
becoming  more  and  more  complicated  and  confusing  instead  of  more 
simple.  A  mere  clinical  classification  which  takes  account  only  of 
symptoms  such  as  vomiting,  constipation,  colic,  diarrhea,  loss  of 
weight,  wasting,  complications  of  dentition,  etc.,  is,  of  course,  not 
sufficient. 

Pathological  study  of  the  subject  has  cleared  up  much  that  was 
obscure,  but  the  clinical  course  often  differs  widely  in  different  indivi- 
duals in  whom  the  anatomical  and  pathological  chang^  are  sunilar. 
In  other,  not  exceptional,  cases,  the  trivial  morbid  changes  demon- 
strable postmortem  bear  no  proportion  at  all  to  the  serious  symptoms 
observed  during  the  course  of  the  disease.  Moreover,  a  classification 
based  on  a  particular  part  of  the  digestive  tract  is  not  admissible, 
because  of  the  intimate  functional  relationship  of  the  various  portions 
which  may  be  involved  at  the  same  time  or  in  rapid  succession. 

Since  Pasteur's  discovery  of  the  bacterial  uncleanliness  of  food, 
bacteriologists  have  given  us  much  information  concerning  the  normal 
and  the  pathological  intestinal  flora  as  well  as  specific  infections  in 
infantile  intestinal  disorders.  But  these  brilliant  investigations  have 
so  far  yielded  relatively  few  practical  results;  at  any  rate,  they  have 
not  enabled  us  to  difterentiate  the  various  clinical  pictures  of  nutri- 
tional derangement,  nor,  according  to  general  statistics,  does  the 
mortality  appear  to  have  been  materially  diminished  by  either  pas- 
teurization or  sterilization  of  milk. 

Physiological  chemistry  teaches  that  disturbances  of  nutrition  com- 
prise not  merely  local  pathological  processes  in  the  gastro-intestinal 
tract,  but  represent  conditions  which  affect  the  whole  organism  in 
that  most  vital  function,  intermediary  metabolism.  But,  so  long  as 
the  more  intricate  functions  of  normal  nutrition  are  shrouded  in 


NUTRITIONAL  DISTURBANCES  203 

niystery,  we  certainly  cannot  lioi)c  to  sohe  the  etiological  prohlcm  of 
its  derangements,  especially  since  idiosyncrasies,  individual  peculiari- 
ties, and  special  environment,  such  as  heat,  infection,  and  hospitalism, 
must  be  taken  into  consideration.  Are  these  nutritional  disorders 
due  to  defective  digestion,  faulty  absorption,  disturbed  metabolism 
and  assimilation,  or  to  intoxication  and  decomposition? 

A  serious  and  very  important  problem  is  the  question  of  food 
anaphylaxis.  It  seems  that  this  phenomenon  even  occurs  in  very 
young  children  so  that  they  are  abnormally  sensitized  toward  the 
proteins  of  milk,  for  example,  or  a  little  later  to  those  of  the  various 
foodstuffs.  The  recognition  of  this  condition  is  still  rather  difficult, 
but  the  introduction  of  these  substances  in  the  diet  will  result  in 
so-called  anaphylactic  shock,  inducing  colic,  nausea  and  vomiting, 
diarrhea,  and  even  fever,  as  well  as  various  skin  manifestations. 

It  is  only  when  scientific  investigation  along  the  lines  of  pathology, 
bacteriology,  and  metabolism  goes  hand  in  hand  with  mature  clinical 
observation  that  we  can  hope  to  make  any  progress  toward  a  solution 
of  these  questions.  Czerny  and  Keller  propose  the  following  clas- 
sification, which  is  based  not  only  upon  scientific  data,  but  is  clinically 
of  the  greatest  value  to  the  physician  in  deciding  upon  the  treatment 
of  the  case : 

1.  Nutritional  disturbances  arising  from  alimentation. 

2.  Nutritional  disturbances  arising  from  infection. 

3.  Nutritional  disturbances  arising  from  congenital  anomalies. 
"Proper  nutrition  makes  for  the  perfection  of  the  coming  genera- 
tion, improper  nutrition  mars  it."  How,  then,  is  a  baby  to  be  fed  in 
order  to  insure  proper  growth  and  development  if  it  cannot  have  the 
advantage  of  the  natural  ideal  food?  The  feeding  problem  in  itself, 
full  of  difficulties,  is  often  still  further  increased  by  a  diversity  of 
individual  circumstances  and  idiosyncrasies  which  must  enter  into  a 
consideration  of  the  question  of  establishing  an  equilibrium  between 
the  quantity  and  the  quality  of  the  food  and  the  infant's  capacity  to 
digest  and  assimilate  it. 

In  the  perfectly  normal  infant  the  amount  and  the  composition  of 
the  food  may  vary  to  a  considerable  degree  without  producing  nutri- 
tional disturbances.  This  is  owing  to  a  great  tolerance  for  the  different 
food  elements,  and  explains  the  common  experience  that  a  normal 
baby  may  thrive  on  a  milk  formula  or  on  food  which  would  cause 
serious  trouble  in  another  less  robust  infant.  It  is  true  that  every 
infant  is  a  law  unto  itself;  nevertheless,  there  are  certain  rules  for  the 
guidance  of  the  physician  who  prefers  scientific  methods  to  empiricism. 

Proper  food  must  make  possible  a  proper  functioning  of  the  intes- 
tinal mucous  membrane,  its  glands  and  its  adnexa.  It  should  incite 
a  sufficient  peristalsis,  and  favor  the  growi;h  of  normal  bacteria.  It 
should  be  sufficient  in  amount  to  maintain  the  body  heat,  and  so 
assimilable  as  to  favor  the  building  up  of  the  body  cells.  Improper 
food, -failing  in  one  or  more  of  these  requirements,  produces  morl)id 
changes  in  the  gastro-intestinal  canal  that  lead  to  derangement  of 


204  NORMAL  DIGESTION 

the  intermediary  metabolism,  followed  by  disturl^ance  of  the  general 
mitrition  and,  eonsequently,  by  a  lessened  power  of  resistance  to 
disease.  It  must  be  emphasized  that  nutrition  and  nutritional  dis- 
turbances are  distinctly  different  in  infants  and  children. 

The  foods  should  contain  fats,  proteins,  and  carbohydrates  in  a 
fairly  definite  percentage,  and  in  such  proportions  as  will  best  meet 
the  nutritional  demands  of  the  baby.  If,  for  any  reason,  it  is  neces- 
sary to  reduce  the  fats  and  proteins  markedly  they  should  be  raised 
to  normal  as  soon  as  possible.  Xo  other  food  element  can  take  the 
place  of  nitrogen  or  proteins.  Carbohydrates  may  temporarily 
replace  the  fats,  but  in  time  the  lack  of  fat  w^ill  produce  serious  nutri- 
tional disturbances.  Too  great  reduction  of  proteins,  fats,  and  salts 
may  result  in  rickets,  scurvy,  anemia,  and  other  forms  of  malnutrition. 

In  artificially  fed  infants  uncomplicated  cases  of  under-nourish- 
ment  resulting  from  simple  lack  of  food  are  rarely  seen.  Usually 
they  are  referable  to  disordered  absorption  or  assimilation,  resulting 
in  chronic  indigestion,  and  originally  brought  about  by  improper 
feeding.  Underfeeding  may  occiu"  in  the  breast-fed  child  if  the 
mother's  milk  is  too  weak  in  composition  or  too  small  in  quantity  or 
when  some  deformity,  such  as  inverted  nipples,  etc.,  interferes  with 
nursing. 

Hare-lip,  cleft-palate,  large  adenoid  vegetations,  or  debility  may 
often  prevent  the  nursling  from  getting  a  sufficient  amount  *of  milk, 
but  this  trouble  is  easily  recognized  and  remedied.  The  infant  fails 
to  gain  or  even  loses  weight;  it  sleeps  well,  is  not  restless,  and  its 
whining  cry  is  neither  frequent  nor  prolonged;  in  the  absence  of 
gastro-intestinal  symptoms,  the  scanty  stools  and  urine  and  a  sub- 
normal temperature  will  clinch  the  diagnosis.  ^ 

Holt  has  dra^^^l  attention  to  the  fact  that  in  the  early  days  of  the 
disorder  there  is  a  rise  of  temperature  to  104°  or  105°  F.  (inanition 
fever),  w^hich,  however,  soon  declines  if  plenty  of  food  is  given.  Infants 
can  be  made  ill  with  a  perfectly  wholesome  food  if  it  be  given  in 
excessive  quantity.  Overfeedmg  may  mean  a  superabundance  of 
all  ingredients  or  of  a  single  one.  It  sometimes  causes  severe  and 
persistent  indigestion  when  the  infant  is  fed  at  irregular  or  too  short 
intervals,  or  is  given  too  much  at  a  single  feeding. 

The  baby  suffers  from  colic  announced  by  a  sharp  piercing  cry, 
which  often  begins  at  a  definite  time  after  feeding  and  is  continued 
until  eructation,  or  vomiting,  or  the  passage  of  flatus  apparently 
brings  relief.  Diu-mg  the  attack  the  extremities  are  rather  cold,  the 
thighs  are  flexed  upon  the  abdomen,  and  the  latter  is  rigid,  evidently 
due  to  a  circulatory  disturbance  in  the  splanch^nc  area  (especially 
of  the  intestinal  walls).  Spitting  frequently  heralds  the  trouble, 
followed  in  some  cases  by  vomiting.  Generally  the  infant  is  cross, 
fretful,  runs  a  slight  temperature,  and  sleeps  restlessly.  Not  infre- 
quently the  baby  suffers  from  facial  eczema  and  seborrhea  of  the 
scalp  (often  limited  to  the  anterior  fontanelle),  though  other  areas 
of  the  skin  may  look  fresh  and  pink  and  show  normal  elasticity. 


DISTURBANCE  OF  BALANCE  205 

These  disturbances  are  seen  in  artificially  fed  as  well  as  breast-fed 
babies;  in  the  latter  a  high  fat  percentage  is  said  to  be  the  etiological 
factor.  The  condition  is  serious,  principally  on  account  of  difficulties 
that  may  arise  during  and  after  weaning.  With  the  artificially  fed 
baby  nutritional  disturbances  and  their  serious  consequences  most 
commonly  result  from  too  large  quantities,  or  too  strong  modifications 
of  milk  or  too  frequent  feedings. 

Too  much  even  of  a  properly  modified  milk  mixture,  given  at  one 
time  or  at  too  short  intervals,  will  often  retard  weight  development; 
therefore,  the  mere  fact  that  a  baby  does  not  gain  but  even  loses 
weight  is  no  indication  for  increasing  its  amount  of  food.  If  other 
causes,  such  as  adenoids,  stomatitis,  syphilis,  and  tuberculosis  can  be 
excluded  from  the  etiology,  a  decline  in  the  weight  curve,  in  spite  of 
a  plentiful  supply  of  proper  food,  strongly  indicates  disturbed  nutri- 
tion. The  digestive  tract  needs  rest.  If  this  is  prevented  by  too 
frequent  feedings,  the  stomach  is  never  emptied  completely;  less 
HCl  is  secreted,  and  is  therefore  not  present  in  a  free  state,  which 
in  turn  acts  unfavorably  on  the  secretion  of  the  pancreas. 

Ambitious  mothers  should  therefore  be  warned  against  the  disas- 
trous consequences  of  excessive  feeding;  not  only  does  it  cause  gastro- 
intestinal disturbances  and  a  predisposition  to  intestinal  infection, 
but  it  may  so  upset  the  equilibrium  of  the  metabolic  processes  that 
it  may  take  weeks  or  even  months  to  restore  the  same.  The  food 
should  be  increased,  not  merely  to  make  the  infant  weigh  more,  or 
because  its  restlessness  and  crying  are  wrongly  interpreted  as  a  sign 
of  hunger,  but  only  when  steadily  declining  weight  is  accompanied  by  a 
small  amount  of  feces  and  urine,  while  the  intestines  are  apparently 
healthy. 

Disturbance  of  Balance. — A  relatively  unobjectionable,  pure  milk, 
given  at  regular  intervals  and  adapted  in  quantity  and  in  composition 
to  the  requirements  of  the  average  infant,  does  not  always  insure 
good  results.  While  most  children  thrive  upon  it,  others,  after  a  few 
weeks  of  comparatively  rapid  gain,  remain  stationary  or  nearly  so 
in  weight  and  in  physical  development.  Increasing  the  quantity  or 
the  strength  of  the  food  does  not  improve  matters;  it  may  even  lead 
to  an  appreciable  decrease  in  weight. 

Curiously  enough  the  baby  hardly  seems  to  be  ill ;  the  pulse,  respira- 
tion, and  the  temperature,  as  well  as  the  urine  show  no  serious  disturb- 
ance, b*ut  the  child  is  restless,  peevish,  and  pale,  though  apparently 
not  in  pain.  The  stools  are  often  fairly  regular,  but  in  fully  developed 
cases  they  are  rather  dry,  light  in  color,  and  offensive  in  odor.  They 
leave  no  stain  on  the  diaper,  and  their  relation  to  litmus  is  alkaline. 
Evidently,  the  fopd  is  not  being  assimilated. 

Proteins  and  carbohydrates  do  not  seem  to  be  the  cause  of  the 
trouble,  because  a  change  to  a  food  rich  in  both  but  poor  in  fat,  given 
in  small  quantities  at  first,  usually  remedies  the  trouble.  The  disturb- 
ance is  due  to  the  fat  of  the  cow's  milk,  only  a  small  percentage  of 
which  is  tolerated,  and  whenever  this  limit  is  exceeded  the  trouble 


206  NORMAL  DIGESTION 

reappears.  We  emphasize  "the  fat  of  cow's  milk,"  on  account  of  the 
remarkable  fact  tjiat  in  these  cases  breast  milk  is  well  borne  in  spite 
of  its  high  fat  content. 

Dyspepsia. — In  artificially  fed  infants,  even  under  the  most  favor- 
able circumstances,  the  digestive  organs  must  perform  an  increased 
amount  of  work,  and  overfeeding,  of  course,  adds  to  this  burden. 
When  combined  with  an  alteration  in  the  osmotic  conditions  in  the 
intestine,  it  can  be  readily  understood  that  it  might  cause  a  certain 
exhaustion  of  the  digestive  and  the  absorptive  capacity.  Naturally, 
intermediary  metabolism  in  turn  is  affected,  and  the  degree  of  derange- 
ment finds  expression  in  the  progressively  severe  symptoms  observed 
in  dj'^spepsia,  intoxication,  and  decomposition. 

The  first  of  these — dyspepsia — often  quickly  follows  a  neglected 
condition  resulting  in  loss  of  weight,  but  the  symptoms  vary  greatly. 
It  represents  a  very  extreme  disturbance  of  nutrition,  the  term  imply- 
ing not  merely  non-digestion,  but  rather  a  disturbed  digestion  through 
the  action  of  the  food  or  its  derivatives.  If  the  digestive  processes 
themselves  are  involved,  dyspepsia  is  not  a  primary  affection,  but  the 
result  of  a  general  condition. 

Thin,  delicate  infants,  especially  those  under  three  months  old,  are 
more  susceptible,  but  even  the  robust  are  not  immune  if  serious  dietetic 
errors  are  made.  Diarrhea,  vomiting,  and  gas  formation  dominate 
the  clinical  picture.  The  stools  are  watery,  green,  and  frequent,  four 
to  six  being  usually  passed  within  twenty-four  hours;  they  contain 
small  curds,  consisting,  not  of  undigested  ffroteins,  but  of  fats  and 
fat  soaps.  Vomiting,  apparently  the  result  of  gastric  irritation, 
may  occur  immediately  after  feeding  or  later.  The  temperature 
exceeds  by  one  or  two  degrees  the  daily  variation  in  healtjfiy  infants. 
The  weight  drops  distinctly  during  the  first  few  days,  then  either 
remains  stationary,  or  declines  slowly. 

Symptoms  of  abnormal  fermentation  in  the  gastro-intestinal  tract — • 
eructations,  foamy  fecal  discharges  passed  with  flatus,  colic,  and  dis- 
tention of  the  abdomen — are  marked  the  higher  the  percentage  of 
carbohydrates,  especially  of  sugar,  in  the  food;  as,  for  example,  in 
condensed  milk.  The  urine  is  negative  as  to  albumin,  sugar,  and 
casts,  but  contains  an  increased  amount  of  ammonia.  The  little 
patient  does  not  appear  seriously  ill,  the  heart,  the  lungs,  and  the 
kidnej^s  seem  unaffected,  but  it  is  peevish,  restless,  and  often  cries 
with  pain. 

Here,  again,  fat  is  at  fault,  as  to  all  appearances  it  lowers  the  tol- 
erance for  sugars,  though  the  latter  (in  the  order  of  then-  injuriousness, 
milk  sugar,  cane  sugar,  and  maltose)  are  tte  principal  cause  of  the 
disorder.  Sugars  and  fats  probably  cause  the  formation  of  acids  which, 
by  withdrawing  the  alkalies  from  the  system,  may  produce  a  relative 
acidosis,  as  evidenced  by  the  increased  ammonia  coefficient  in  the 
urine.  If  the  condition  is  recognized  in  time,  and  either  good  breast 
milk  is  given  or  the  fats  and  sugars  are  reduced  to  a  minimum,  improve- 
ment will  most  likely  set  in.    The  chief  danger  lies  in  the  fact  that 


ALIMENTARY  INTOXICATION  207 

the  disorder  may  go  on  to  intoxication  and  decomposition,  which 
would  be  serious  for  the  weakened  child. 

Alimentary  Intoxication. — Alimentary  intoxication  is  a  severe  dis- 
turbance of  intermediary  metabolism  with  evidences  of  relative 
acidosis,  a  condition  resembling  diabetes  or  uremia,  which  follows 
dyspepsia  when  the  injurious  food  is  continued.  It  is  characterized 
by  its  sudden  onset  (there  is  also  a  lingering  form),  diarrhea,  vomiting, 
high  fever,  sugar  in  the  urine,  leukocj^tosis,  and  eventually  collapse. 
On  account  of  its  most  prominent  symptoms,  the  disease  was  formerly 
thought  to  be  bacterial  in  origin,  and  w^as  classified  as  acute  gastro- 
enteritis, or  as  cholera  infantum. 

It  is  true,  bacterial  infection  can  scarcely  be  disregarded  as  an  etio- 
logic  factor,  but  is  it  the  chief  one?  The  experience  that  most  of  these 
cases,  if  seen  the  first  day,  respond  within  twenty-four  to  forty-eight 
hours  to  starvation  treatment  certainly  does  not  favor  this  assump- 
tion; but,  on  the  contrary,  points  to  the  food  as  the  primary  cause. 
Indeed  Finkelstein  and  Meyer  have  proved  that  an  excess  of  milk 
sugar  can  produce  the  whole  symptom-complex  of  this  intoxication, 
especially  if  the  food  has  a  high  fat  percentage.  That  the  disorder 
is  not  only  intestinal  but  is  also  connected  with  metabolism  is  shown 
by  the  presence  of  sugar  in  the  urine. 

There  is  a  possibility  that  milk  decomposed  by  bacteria  before  or 
after  ingestion  may  irritate  the  intestine,  and  after  its  absorption 
derange  the  metabolism.  So  far,  however,  the  toxic  action  of  these 
products  has  not  been  definitely  demonstrated,  and  we  have  reason 
to  believe  the  primary  cause  to  be  a  dietetic  one,  and  that  the  decom- 
position of  the  food  and  the  presence  of  pathogenic  microorganisms, 
as  well  as  the  depressing  effect  of  heat  are  not  unimportant  additional 
factors. 

Previous  alimentary  disorders,  a  lowered  resistance  from  any  cause, 
and  artificial  feeding  in  itself,  create  a  tendency  to  the  disturbance. 
The  onset  is  usually  sudden,  the  temperature  rises  steadily  to  104° 
or  105°  F.,  or  it  may  fluctuate,  and  in  the  case  of  collapse  it  falls  sud- 
denly. Vomiting  and  diarrhea  occur  early,  though  the  latter  is  not 
always  severe — four  or  five  stools  daily — but  when  they  reach  ten  to 
forty,  the  sunken  fontanelle,  the  pale  skin,  and  the  dry  mucous  mem- 
branes are  symptoms  that  cannot  be  mistaken. 

In  the  milder  cases  the  baby  looks  sick,  the  face  is  pale,  expression- 
less, and' sleepy-looking,  w^hile  in  the  more  serious  ones  the  child  is 
apathetic,  and  never  smiles.  The  half-opened  eyes,  together  with  a 
pinched  expression,  a  bluish-gray  color  of  the  skin,  and  coma  make 
the  prognosis  doubtful.  The  more  severe  the  diarrhea,  the  more 
decided  is  the  los^  in  weight.  After  the  initial  loss  (sometimes  as 
much  as  half  a  pound  to  two  pounds  a  day)  the  weight  remains 
stationary  or  declines  slowly.  The  respirations  deepen,  their  rhythm 
is  accelerated,  and  the  infant  gasps  for  air. 

On  examining  the  chest  signs  of  hypostatic  pneumonia  are  often 
found.     On  account  of  the  great  loss  of  fluid  no  anemia  is  demon- 


208  NORMAL  DIGESTION 

strable,  but  leukocytosis  seems  always  to  be  present.  The  disturbed 
circulation  is  manifested  by  the  pallor  of  the  skin,  cerebral  symptoms, 
hypostatic  pneumonia,  and  meteorism,  the  latter  resulting  from 
splanchnic  congestion.  Glycosuria  is  a  constant  and  early  symptom. 
Albumin  and  casts  are  found  in  the  urine,  but  the  absence  of  leukocytes 
and  epithelial  cells  excludes  inflammation  of  the  kidneys. 

Decomposition  represents  the  complete  failure  of  the  digestion, 
which  progressively  affects  the  resources  of  the  organism,  and  finally 
leads  to  its  complete  breakdown.  The  condition  usually  follows  a 
neglected  digestive  disorder,  repeated  attacks  of  dyspepsia,  or  a 
toxic  condition,  and  is  characterized  by  nervous  irritability,  emacia- 
tion, irregular  respiration,  subnormal  temperature,  and  a  slow  pulse; 
the  urinary  findings  are  normal.  The  malady  is  aggravated  by  taking 
food,  and  leads  rapidly  to  decomposition  of  the  body.  In  this  advanced 
stage  the  infant's  organism  seems  to  have  lost  all  power  of  assimilating 
even  minute  quantities  of  food.  To  all  appearances,  a  true  reversal 
of  nutrition  has  taken  place,  and  the  child  has  no  chance  for  its  life. 

Even  in  mild  cases  improvement  is  tardy.  The  general  state  of 
the  patient  undergoes  a  radical  change,  it  is  nervous,  sleeps  badly, 
cries  for  hours  at  a  time,  and  can  only  be  quieted  by  the  bottle,  which 
is  taken  eagerly;  it  seems  always  hungr}^  and  thirsty,  yet  continually 
loses  flesh.  The  weight  falls  with  the  progress  of  the  disease,  at  first 
perhaps  only  an  ounce  per  day,  but  the  decline  is  more  rapid  as  decom- 
position advances.  The  dry,  inelastic  skin  soon  hangs  in  loose  folds 
over  the  bones,  the  eyes  become  large  and  hollow,  the  lips  pale,  and 
the  skin  assumes  a  grayish-blue  hue,  giving  the  child  an  unsightly, 
ape-like  appearance — the  horror  of  the  pediatrician. 

The  bowel  movements  vary  in  character.  They  may/resemble  the 
normal  or  they  may  be  slimy,  loose  and  offensive,  or  may  show  all 
the  characteristics  of  soap-stools.  The  urine,  rather  large  in  amount, 
is  negative  except  for  indican;  sugar  and  albumin  are  found  only  in 
the  last  stages.  The  vital  forces  seem  to  be  slowly  ebbing  away, 
sometimes  interrupted  by  a  short  but  passing  toxic  excitation.  The 
pulse  becomes  small,  frequent,  and  gradually  falls  from  110  to  80,  70, 
or  even  60.  Deep  breathing,  sighing  respu-ations,  finally  assuming 
the  Cheyne-Stokes  type,  and  a  frequently  subnormal  temperatm-e, 
possibly  now  and  then  interrupted  by  a  sudden  rise  to  be  followed  by 
a  sharp  decline,  complete  the  pitiful  picture.  The  gradually  increas- 
ing relaxation  may  end  in  collapse,  or  death  may  occur  from  terminal 
pneumonia,  otitis,  etc. 

Every  physician  knows  the  picture  of  atrophy  clinically,  but  the 
theoretical  explanation  is  modern,  and  merits  attention.  The  decom- 
position affects  first  the  fat,  only  a  small  amount  of  which  is  tolerated, 
and  only  for  a  short  time.  A  limited  percentage  of  carbohydrates 
can  be  borne  with  relative  impunity,  especially  if  the  fats  are  cut  out. 
Casein  and  albumin  also  seem  to  favor  the  decomposition. 

No  other  problem  of  infant  feeding  shows  more  clearly  the  tremen- 
dous advantage  of  human  milk,  which  is  the  only  salvation  for  very 


EXAMINATION  OF  FECES  209 

^'oullg■  infants.  When  fed  npon  it  mild  cases  of  decomposition  improve 
rapidly,  in  spite  of  the  fats  and  carbohydrates,  and  even  severe  ones 
have  a  good  chance  of  recovery  under  careful  management. 

Feces. — Examination  of  the  feces  is  no  more  important  than 
the  observation  of  the  child's  weight,  the  skin,  the  turgor,  and  its 
activity;  but,  in  the  majority  of  cases,  the  first  evidence  of  nutritional 
disturbance  is  an  increased  number  of  bowel  movements.  First,  their 
looseness,  then  their  change  in  color,  later  curds,  perhaps  the  presence 
of  blood  and  an  excess  of  fats  or  of  mucus  (pus  is  not  often  visible) 
attract  our  attention. 

These  changes  are  significant  of  a  diseased  condition,  but  not  neces- 
sarily of  any  special  disease.  Almost  all  of  the  diseases  of  infancy 
may  be  accompanied  by  diarrhea;  this  holds  true  even  in  certain  cases 
of  syphilis  and  tuberculosis.  Although  the  most  severe  form  of 
diarrhea  is  seen  in  intestinal  intoxication,  on  the  other  hand,  intoxica- 
tion may  cause  only  a  slight  diarrhea. 

In  studying  the  feces  then,  as  to  their  color,  consistency,  composi- 
tion, odor  and  bulk,  or  in  comparing  them  with  the  normal,  we  must 
not  forget  that  from  time  to  time  even  in  the  healthy  infant  the 
movements  may  be  more  or  less  watery,  or  may  contain  coarse  white 
flakes,  without  any  appreciable  functional  disturbance  in  the  gastro- 
intestinal tract.  As  mentioned  before,  small  whitish  particles  in  the 
feces  of  breast-fed  infants  are  not  always  casein  but  often  are  the 
so-called  milk-granules  of  Uffelmann.  For  the  characteristics  of 
normal  stools  we  refer  to  the  description  on  pages  194  and  273. 

The  amount  of  the  stool  is  increased  in  all  disorders  of  nutrition 
except  in  starvation  which  is  merely  the  result  of  lack  of  food.  In 
acute  illness  the  more  numerous  the  movements  and  the  larger  the 
total  bulk,  the  greater  the  resulting  exhaustion.  In  some  chronic 
affections  the  quantity  of  the  feces  discharged  may  be  very  large, 
indicating  a  marked  diminution  of  the  child's  absorptive  powers. 
In  this  way  the  baby  is  starved  in  spite  of  its  consuming  a  sufficient 
amount  of  digestible  food. 

x^fter  the  first  few  weeks  of  life  the  healthy  infant  has  one  to  three 
passages  per  day;  if  artificially  fed,  even  five  are  not  pathological, 
other  characteristics  being  normal.  Their  number  is  slightly  increased 
in  affections  of  the  upper  intestine,  while  in  inflammatory  processes 
of  the  colon  as  many  as  twenty  are  not  uncommon. 

The  feaction  of  the  feces  is  said  to  be  slightly  acid  in  the  breast-fed 
and  neutral  or  alkaline  in  the  bottle-fed  baby.  Acidity  can  be  demon- 
strated by  litmus  in  cases  of  fat  indigestion  (due  to  fatty  acids)  and 
of  carbohydrate  intolerance  (due  to  acetic  and  lactic  acids) ;  alkalinity, 
however,  may  be^  shown  where  putrefaction  predominates,  as  in  pro- 
tein indigestion.  The  reaction  of  the  intestinal  contents  differs  in 
dift'erent  parts  of  the  intestines,  and  doubtless  depends  to  some  extent 
on  the  kind  of  food  taken.  It  probably  largely  determines  the  variety 
of  bacteria  flourishing  in  the  gastro-intestinal  canal,  although  the  con- 
trary is  claimed — that  the  microorganisms  present  determine  the  reaction. 
14 


210  NORMAL  DIGESTION 

The  color  of  the  stools  in  morbid  conditions  varies  so  greatly  from 
the  normal  that  it  is  impossible  to  describe  all  the  variations.  The 
stools,  normally  a  golden-yellow  in  the  breast-fed,  and  a  lighter 
yellow  in  bottle-fed  babies,  become  brownish  when  cereals  are  added 
to  the  food.  When  the  solids  are  much  reduced,  as  in  acute  and 
copious  diarrheas,  the  discharges  may  lose  all  color  and  look  like 
serum,  or  like  water  containing  white  flakes  of  lymph  (the  so-called 
rice-water  stools). 

Clay-colored  stools  are  abnormal,  but  do  not  necessarily  indicate 
a  serious  condition.  They  are  often  due  to  a  diminished  amount  of 
bile  (as  from  biliary  obstruction)  or  to  an  excess  of  undigested  fat. 
Ashen-colored  stools,  however,  are  not  alwa^'s  referable  to  the  absence 
of  bile  or  bile  salts.  A  marked  decrease  in  the  hydrobilirubin  content, 
a  reduction  product  of  bilirubin  from  which  the  normal  feces  derive 
their  color,  produces  urobilinogen,  a  colorless  substance  normally 
found  in  the  dry  whitish  stool  of  fat  constipation.  Bilirubin  when 
oxidized  changes  into  biliverdin,  which  is  supposed  to  be  the  cause 
of  the  so-called  green  stools  so  frequentl}"  seen  in  infantile  diarrhea. 

Formerly  this  green  color  was  supposed  to  be  due  to  the  action  of 
bacteria,  and  for  a  time  this  assumption  seemed  to  be  confirmed  by 
the  appearance  of  green  stools  in  institutional  bottle-fed  infants. 
Sometimes  the  stools  are  yellow  when  passed,  but  acquire  a  greenish 
tinge  on  the  surface  after  exposure  to  the  air.  Practically  all  shades 
of  green  are  observed,  owing  to  the  mixture  of  green,  yellow,  white, 
and  brown.  The  colored  stools  in  themselves  are  not  significant  of 
any  particular  disease,  but  merely  indicate  an  abnormal  condition. 

Calomel  medication  often  produces  green  stools,  but  this  color 
disappears  as  soon  as  the  drug  is  excreted,  and  probaWy  indicates 
an  excess  of  biliverdin  which  is  not  reabsorbed  because  of  the  hurried 
bowel  movement.  An  admixture  of  blood  makes  the  feces  look  red 
when  they  come  from  the  lower  part  of  the  bowels  and  reddish-black 
or  tarry  from  lesions  higher  up.  Iron,  bismuth,  and  manganese  taken 
as  medicine  all  make  the  feces  more  or  less  black,  the  shade  depending, 
of  course,  upon  the  size  of  the  doses  and  the  intervals  between  them. 

The  odor  of  the  defecations  is  caused  by  gases  which  form  under 
the  influence  of  bacteria  in  the  digestive  tract.  In  infants  fed  entirely 
on  breast  milk  or  properly  modified  cow's  milk,  the  odor  is  usually 
slight,  but  it  becomes  stronger  when  other  articles  are  added  to  the 
food;  it  is  supposed  to  be  sour  or  pungent  in  acid  fermentation 
(favored  by  carbohydrates),  and  foul  when  putrefactive  processes 
predominate.  The  latter  are  probably  not  always  due  to  protein 
indigestion,  but  often  to  decomposition  of  intestinal  mucus  or  pus 
which  is  often  present  in  intestinal  irritation.  In  fat  indigestion 
the  fecal  discharges  smell  rancid  and  sour. 

Although  these  statements  cannot  be  offered  as  scientifically  proved 
facts,  they  may  be  helpful  in  diagnosis  and  treatment,  since  they 
indicate  the  cutting  down  of  carbohydrates  in  excessive  fermentation 
and  the  reduction  of  the  percentage  of  proteins  in  putrefaction. 


COMPOSITION  OF  FECES  211 

The  consistency  of  the  feces  depends  chiefly  upon  the  water  and 
the  fat  contents.  Normal  discharges  of  infants  fed  on  milk  are  free 
from  lumps  and  are  of  a  butter-like  consistency — semisolid.  They 
gradually  become  formed  when  other  kinds  of  food  are  taken  and 
their  passage  through  the  large  intestine  is  delayed.  A  liquid  state  is 
just  as  abnormal  as  a  too  solid  one.  Copious  watery  diarrhea  tends  to 
dehydrate  and  to  demineralize  the  system  and,  therefore,  is  dan- 
gerous, aside  from  the  fact  that  absorption  must  suffer  considerably 
if  the  food  is  hurried  through  the  gut.  Thin  and  watery  stools  are 
met  with  in  typhoid  fever,  in  gastro-enteritis,  in  rectal  stricture,  and 
often  after  hydragogue  cathartic  medication. 

Composition. — ^In  addition  to  the  substances  ingested  as  food,  the 
fecal  discharges  contain  bile,  mucus,  epithelial  debris,  residues  of 
secretions,  and  many  bacteria;  in  diseased  conditions,  blood,  mem- 
branes, and  pus  may  also  be  found.  A  certain  amount  of  mucus  is 
normally  present  in  the  feces,  but  as  it  is  mixed  it  is  not  very  apparent. 
It  may  be  found  in  excess  where  there  has  been  prolonged  irritation 
by  hard  scybala  as  -well  as  in  other  digestive  disturbances;  but 
it  may  be  much  increased  in  purely  functional  conditions,  therefore 
is  not  always  indicative  of  intestinal  inflammation.  It  is  discharged 
either  in  little  balls  (resulting  from  peristalsis)  from  the  small  intestine, 
or  in  stringy  fragments  from  the  colon,  and  may  make  up  as  much  as 
one-third  of  the  fecal  mass. 

Excessive  fat  in  the  food  may  cause  either  large,  hard,  dry,  crumbly 
stools,  which  do  not  even  soften  when  a  soapsuds  enema  is  given,  or 
loose,  greasy  movements  which  look  like  oil.  Often  such  feces  are 
sour-smelling,  yellow,  greenish-yellow,  or  even  green  in  color,  and 
have  the  curdled  appearance  of  scrambled  eggs.  Sometimes,  however, 
large,  gray,  putty-like  movements  of  a  peculiar  ammoniacal  odor  are 
passed.  •  Very  little,  if  any,  protein  remnants  of  the  food  are  found 
in  the  feces  of  breast-fed  babies,  while  the  stools  of  bottle-fed  babies 
may  contain  a  little  more. 

Occasionally  undigested  fat  and  balls  of  mucus  are  mistaken  for 
casein  curds;  the  latter  are  large,  smooth,  white  or  grayish,  bean-like 
bodies,  and  frequently  occur  in  otherwise  normal  stools.  They  may 
mean  nothing  but  a  simple  non-digestion  of  the  casein;  in  fact,  they 
are  said  to  disappear  when  boiled  milk  is  given  and  to  reappear  on 
feeding  raw  milk. 

Blood  is  not  infrequently  seen  in  the  stools  in  severe  intestinal 
conditions,  probably  more  from  congestion  than  ulceration.  Hard 
fecal  masses  are  often  streaked  with  bright  red  blood  which  comes 
from  a  small  tear  in  the  anal  mucous  miembrane,  or  occasionally  from 
small  bleeding  polypi.  Small,  frequent  stools  of  blood  and  mucus 
only,  passed  with  straining,  point  strongly  to  intussusception.  In 
melena  neonatorum  the  stools  are  tarry  black.  Pus  may  be  seen  in 
rare  cases  of  communicating  ischiorectal  abscess,  gonorrheal  proctitis, 
or  impacted  foreign  bodies. 


CHAPTER   X. 
FRESH  XLll  IX  THE  TREATMENT  OF  DISEASE. 

One  must  always  study  all  the  factors  leading  up  to  and,  possibly, 
causing  disease,  and  before  deciding  the  positive  influence  of  one 
factor,  eliminate  wholly  or  in  part  other  etiological  influences. 

In  considering,  therefore^  the  role  that  fresh  air  plays,  "controls" 
should  be  employed,  as  far  as  possible,  for  the  comparison  of  a  series 
of  cases  of  the  same  type  of  disease  living  under  similar  conditions 
should  enable  one  to  draw  fairly  accurate  conclusions. 

My  first  work  in  fresh  air  treatment  began  some  fourteen  years 
ago  in  the  children's  wards  of  the  Philadelphia  Hospital.  The  wards 
were  large,  the  milk  fairly  good,  enough  nurses  were  on  duty  to  keep 
the  children  fed  according  to  my  directions,  they  were  bathed  regularly 
and  kept  clean;  but  in  the  wards  where  the  very  young  infants,  mostly 
foundlings,  were  placed,  the  results  were  very  unsatisfactory.  ]\Iuch 
depended  upon  the  physical  condition  of  the  infant  on  admission. 
A  frail  infant,  perhaps  prematiue  and  under  normal  weight,  would 
gain  for  a  few  weeks  at  best,  then  remain  stationary  in  weight,  finally 
gradually  lose  weight,  begin  to  have  diarrhea  and  die.  Robust  infants 
on  admission  often  did  well  for  three  months.  The  same  symptoms 
after  this  period  began  to  develop  as  in  the  infants  admitted  in  a  con- 
dition of  malnutrition  and,  in  spite  of  my  best  efforts,  many  of  these 
robust  children  died.  ^ 

Infants  of  the  same  type  in  my  private  practice  were  almost  without 
exception  doing  well.  Convinced  that  neither  the  food,  nursing,  nor 
general  care  of  these  hospital  infants  was  at  fault,  and  that  the  so-called 
hospitalism  was  nothing  but  lack  of  fresh  air,  and  lack  of  outdoor  air, 
I  ordered  these  children,  in  the  month  of  January,  placed  for  two 
hours  each  day  on  the  fire-escapes. 

The  cribs  were  simply  moved  out  upon  the  fire-escapes,  and  towels 
pinned  over  the  top  of  both  ends  of  the  crib,  as  wind  shields.  The 
infant  mortality  began  to  lessen  immediately,  and  I  began  to  see  some 
hope  for  my  infant  hospital  patients.  In  the  following  two  or  three 
years,  during  my  service  in  January,  February  and  ]\Iarch  of  each 
year,  I  had  the  children,  for  a  number  of  hours  each  day,  unless  it 
was  raining  or  snowing,  carried  down  to  the  large  open  space  facing 
the  hospital  buildings,  and  kept  in  small  hammocks.  These  infants 
were  always  bundled  up  in  blankets,  their  heads  well  covered,  and 
their  eyes,  nose  and  mouth  covered  with  a  gauze  veil.  They  did 
remarkably  well;  so  well,  in  fact,  that  instead  of  my  infants  dying 
most  of  them  began  to  gain  in  weight  and  health,  and  the  deaths  were 
almost  entirely  in  infants  under  three  months  of  age,  whose  condition 
was  distinctly  bad  upon  admission  to  the  hospital. 


FRESH  AIR  IN  THE  TREATMENT  OF  DISEASE  213 

I)uri]ig  the  past  ekn-cji  years  tlie  infants  Jiave  been  placed  in  the 
new  modern  and  np-t()-(hite  building  of  the  Philadelphia  Hosi)ital. 
The  wards  are  large,  the  aii-  space  ample,  the  milk  the  \'ery  best; 
porches  surround  the  hospital  on  two  sides,  the  infants  practically 
have  an  abundance  of  fresh  air  day  and  night,  and  they  do  as  well 
as  could  be  hoped  for.  I  am  no  longer  a  pessimist  when  in  the  infants' 
ward,  but  an  optimist.  In  the  new  Jefferson  Hospital,  where  I  am  on 
duty  the  entire  year,  the  children  have  an  ideal  ward  on  the  eighth 
floor,  large  windows  on  three  sides  with  a  large  roof  garden  adjoining, 
the  latter  fitted  up  with  every  convenience,  such  as  hammocks,  shade, 
wind  shields,  etc.  The  roof  garden  is  used  all  the  year  round,  winter 
and  summer,  and  the  results  are  most  encouraging. 

Of  all  the  factors  which  have  contributed  to  the  reduction  of  this 
infant  mortality,  fresh  air  has,  in  my  opinion,  been  the  one  of  prime 
importance. 

During  the  last  nine  years  in  my  service  in  the  Philadelphia  Hos- 
pital, I  have  treated  all  my  severe  cases  of  broncho-  and  lobar  pneu- 
monia in  children  of  all  ages  by  the  fresh  air  method.  These  infants 
and  children,  as  soon  as  taken  ill,  are  removed  from  the  general  ward 
and  placed  in  a  special  room  provided  for  such  cases.  The  room  holds 
six  cribs  comfortably,  and  rarely,  during  my  service  in  the  last  three 
years,  has  a  bed  been  vacant.  Many  of  these  cases  are  secondary 
bronchopneumonias.  A  large  percentage  of  the  children,  in  fact  most 
of  them,  are  hospital  children,  but  the  results  have  been  so  different 
from  those  following  the  methods  of  years  ago,  that  I  have  lost  much  of 
my  dread  of  pneumonia  as  a  hospital  disease.  True,  these  cases  have 
good  nursing,  good  care  and  every  possible  attention,  but  still  they 
are  cases  of  pneumonia  in  hospital  practice  and  they  do  remarkably  w^ell. 

In  another  similar  room  in  the  same  hospital,  during  the  same 
period  of  time,  I  have  been  treating  my  typhoids.  Occasionally, 
I  have  a  typhoid  under  two  years  of  age,  most  of  them  are  over 
three,  and  the  average  age  about  six  years.  The  typhoid  cases  come 
from  the  same  class  of  patients  as  the  pneumonias,  and  they  do  so 
much  better  in  the  fresh  air  that  nothing  could  persuade  me  to  return 
to  the  old  method  of  treatment,  similar  in  every  way  to  the  present, 
but  minus  the  fresh  air.  The  rooms  where  the  typhoids  and  pneu- 
monias are  kept  have  large  windows  on  two  sides,  and  an  open  door 
on  a  third  side;  these  are  kept  open  day  and  night;  a  distinct  effort 
is  made  to  keep  the  hands  and  feet  of  these  children  warm  by  gloves, 
stockings  and  hot-water  bags,  but  the  rooms  are  always  cold,  except 
for  a  few  minutes  every  two  or  three  hours,  when  the  windows  are 
closed  and  all  the  children  carefully  examined  as  to  cleanliness,  etc. 

The  few  cases  o|  tuberculosis  are  kept  in  a  special  portion  of  one 
of  the  porches,  living  practically  in  the  open  air.  Arrangements  are 
just  being  made  for  a  special  pavilion  for  these  cases.  In  the  Jefferson 
Hospital  the  pneumonia  and  typhoid  cases  are  treated  by  the  fresh 
air  method,  and  do  infinitely  better  than  formerly,  when  the  fresh 
air  treatment  was  not  employed. 


214  FRESH  AIR  IN  THE  TREATMENT  OF  DISEASE 

111  privatt'  practice  for  eleven  years  T  lia\e  treated  all  infants  and 
children,  sick  and  well,  with  fresh  air;  in  fact,  on  my  first  visit  to  the 
child,  I  try  to  instill  into  the  mother's  mind  the  principle  that  fresh  air 
differs  from  impure  air  as  much  as  fresh  milk  from  impure  milk.  Once 
gain  her  consent,  and  the  treatment  is  an  assured  fact.  I  am  more 
than  surprised  to  see  the  willingness  with  which  most  mothers,  no 
matter  what  their  social  status  may  be,  enter  into  the  treatment. 
The  physician  must  be  enthusiastic;  the  mother  is,  in  my  experience, 
readily  convinced. 

During  both  the  winters  and  the  summers  of  the  past  eleven  years,  I 
have  kept  numerous  infants  out  of  doors  all  day  long,  except  bringing 
them  in  occasionally  to  the  house  for  the  purpose  of  removing  soiled 
clothing,  and  I  have  never  in  all  that  time  seen  a  single  injurious 
symptom  result,  and  I  am  positive  it  has  been  the  means  of  saving 
many  lives.  Rickets,  scrofulosis,  gastro-intestmal  disease,  any  and 
all  conditions  are  benefited  by  the  treatment.  Measles,  in  hospital 
cases,  I  treat  in  separate  rooms,  each  room  opening  upon  a  common 
porch,  surrounded  by  glass.  During  the  first  few  days  the  children 
are  kept  in  the  cool,  darkened  rooms,  then  moved  to  cribs  on  the 
porch;  the  windows  on  the  porch  are  opened  more  or  less,  insuring 
an  abundance  of  fresh  air.  The  influence  of  climate  associated  with 
rest  in  the  treatment  of  nephritis  and  cardiac  disease  is  now  so  well 
recognized  that  comment  is  unnecessary. 

It  is  an  interesting  question,  which  experience  alone  can  decide, 
as  to  what  arrangement  will,  in  the  future,  be  made  to  control  the 
degree  of  temperature  in  which  these  children  are  kept  when  in  the 
fresh  air.  In  hospital  practice  it  has  been  my  custom  to  keep  infants 
under  three  months  for  a  few  days  in  the  cool  air  of  th^ward  before 
putting  them  outdoors — the  temperature  of  the  ward  usually  being 
near  60°  F.  in  the  cooler  months.  In  private  practice,  where  the 
temperature  can  be  more  absolutely  controlled  for  each  individual 
case,  I  gradually  but  rapidly  lower  the  temperature  of  the  room  to 
60°  F.,  then,  dressing  the  child  exactly  as  if  it  were  to  be  taken  out- 
doors, gradually  lower  the  temperature  of  the  room  for  a  few  hours 
each  day  until  it  approximates  the  degree  of  temperature  in  the  fresh 
outside  air.  Indifferent  temperature  feels  neither  warm  nor  cold 
(Wachenheim) ,  and  is  most  restful.  In  children,  indifferent  tempera- 
ture is  above  75°  F.  in  summer  in  summer  clothing,  and  above  65° 
F.  in  w^inter  in  winter  clothing,  and  varies  with  age  and  vitality. 
Temperatures  above  indifferent  are  not  sedative,  but  cause  a  contin- 
uous stimulation  that  is  harmful  if  prolonged,  ending  in  exhaustion. 
The  same  author  also  says,  "Young  children  stand  severe  cold  badly.'' 
This  is  not  my  experience,  if  by  "severe  cold"  is  meant  the  ordinary 
winter  weather  in  Philadelphia.  True  it  is  that  these  children  are 
bundled  up  from  head  to  foot,  lie  in  a  comfortable  baby  coach,  and 
have  thick  gloves,  stockings,  veil  and  perhaps  a  hot-water  bag,  but 
they  do  breathe  the  cool  air,  and  they  all  do  well.  Two  or  three  rahiy 
or  snowy  days  will  convince  any  one;  the  children  are  kept  indoors 
in  a  warm  room  and  they  fuss  and  cr}-;  out  of  doors  they  are  quiet. 


FRESH  AIR  IN  THE  TREATMENT  OF  DISEASE  215 

Humidity  has  an  influence  by  cheekinn'  (^r  increasing  the  evaporation 
from  the  body,  and  further  studies  along  this  Hue  will  be  of  value. 

The  distance  above  sea  level  exerts  a  certain  distinct  influence  upon 
the  skin,  kidneys  and  blood,  and  induces  metabolic  changes  of  impor- 
tance. The  influence  of  a  few  months  of  camp  life  on  growing  boys 
is  appreciated  by  every  one.     "Camp  life"  is  fresh-air  treatment. 

When  it  is  possible  to  select  the  kind  of  fresh  air  desired,  certain 
broad  lines  may  be  followed.  Increase  of  heat  production,  and, 
consequently,  an  augmented  metabolism,  are  rendered  necessary  by 
cold,  dry  air  of  high  altitudes.  This  is  proven  by  the  larger  amount 
of  carbonic  acid  gas  given  off  by  the  lungs.  It  also,  as  a  rule,  increases 
the  red  blood  cells  during  the  first  few  weeks  of  treatment.  High 
altitudes  are  good  for  children  with  incipient  tuberculosis  or  an 
inherited  tendency  to  tuberculosis. 

Fresh  seashore  air  is  of  decided  benefit  in  infants  and  children  con- 
valescing from  severe  illnesses,  especially  gastro-intestinal  in  type. 
It  is  of  distinct  benefit  also  in  the  so-called  strumous  type. 

Fresh  country  air  is  better  than  fresh  city  au".  Rural  districts 
are  better  than  urban;  but  density  of  population,  such  as  one  sees 
often  in  large  cities,  does  not  necessarily  imply  lack  of  fresh  air.  The 
number  of  people  living  in  a  given  area  may  be  very  large,  but  if 
they  live  in  comfortable  houses,  keep  the  windows  open,  and  live 
under  the  best  hygienic  conditions,  fresh  air  can  be  secured  in  abun- 
dance, and  infants  and  children  do  w^ell.  If  the  same  number  of 
people  living  in  the  same  area  do  not  have  an  abundance  of  fresh  air, 
the  infants  and  children  do  badly.  Density  of  population  may  have 
much  or  little  to  do  with  fresh  air. 

Statistics  prove  conclusively  that  in  all  countries  where  the  mothers 
work  in  industrial  plants,  necessitating  their  absence  from  home  a 
large  portion  of  the  day,  the  infants  and  children  show  a  much  higher 
mortality  rate,  owing  to  the  fact  of  their  being  kept  indoors,  than 
is  found  among  the  children  of  the  same  class  of  people  living  under 
exactly  similar  conditions  except  that  the  mothers  live  at  home  and 
have  time  to  keep  their  children  in  the  fresh  air. 

In  Berlin,  1903,  Newman  investigated  2701  infant  deaths.  Where 
the  families  were  in  one-room  dwellings  he  found  1792  deaths;  in 
two-room  dwellings,  754  deaths;  in  three-room  dwellings,  122  deaths; 
in  larger  dwellings,  43  deaths.  Can  anything  prove  more  conclusively 
than  this  the  power  fresh  air  has  to  preserve  life,  or  the  rapidity  with 
which  bad  or  impure  air  can  cause  death?  Unfortunately  for  the 
infant  and  young  child,  the  ignorance  of  many  mothers,  the  super- 
stitions and  traditions  of  others,  and  the  carelessness  of  a  few,  are 
the  greatest  barrie^rs  to  the  keeping  of  children  in  the  fresh  air. 

During  the  past  few  years  much  has  been  written  upon  the  impor- 
tance of  fresh  air  for  very  young  children,  and  the  subject  of  fresh 
air  as  an  aid  in  the  treatment  of  disease  is  not  of  recent  date.  In 
the  History  of  the  Medical  Society  of  the  State  of  New  York,  as 
published  in  the   New    York  State  Journal  of  Medicine,  it  is  shown 


216  FRESH  AIR  IN  THE  TREATMENT  OF  DISEASE 

that  in  the  early  part  of  the  nineteenth  century  the  dangers  of  dust- 
laden  air  were  recognized;  the  influence  that  certain  occupations 
exerted  upon  the  etiology  of  tuberculosis  was  appreciated,  and  even 
at  that  date  "cold  air"  was  used  in  the  treatment  of  typhus  fever. 

In  one  of  these  essays  upon  "The  Influence  of  Trades,  Professions 
and  Occupations  in  the  United  States  on  the  Production  of  Disease," 
the  author  shows  clearly  how  the  crowding  together  of  children  in 
the  tenement  districts  produced  gastro-intestinal  disease  and  death, 
proving  that  at  this  distant  period  the  virtue  of  fresh  air  was  appre- 
ciated. 

In  1850  to  1860,  Dr.  Clark  treated  a  very  large  number  of  cases  of 
typhus  fever  in  Bellevue  Hospital  by  the  fresh  air  method.  The 
windows  were  removed;  in  winter  stoves  w^ere  placed  before  the 
open  spaces  to  insure  a  slight  heating  of  the  air,  but  the  patients  were 
given  the  fresh-air  treatment,  as  we  understand  it  in  the  fullest  sense 
today.  The  results  were  vastly  superior,  the  death-rate  very  markedly 
lower  than  the  mortality  among  the  same  class  of  patients  in  the 
same  hospital  at  the  same  period  in  the  hands  of  the  other  members 
of  the  staff  where  fresh  air  was  not  used.  It  is  a  well-known  fact 
that  in  times  of  w^ar  patients  treated  in  the  fresh  air  of  tents  always 
do  better  than  those  confined  in  hospitals. 

The  phenomena  of  child  life  have  often  occupied  the  attention 
of  psychologists,  and  new  theories  for  children  are  formed  every  day 
by  educators.  Theoretically,  they  are  making  the  superchild,  soon 
to  be  the  father  of  the  superman.  We,  however,  should  be  quite  con- 
tent if  parents  could  be  taught  to  appreciate  the  advantages  accruing 
to  the  child  from  correct  feeding,  combined  with  fresh  air,  and  the 
influence  they  exert  upon  the  mental  and  physical  deyelopment  of 
the  growing  child. 

Everyone  should  be  made  to  understand  how  important  it  is  for 
the  very  young  to  be  taught  how  to  stand,  lie  down,  and  sit  properly, 
and  that  deep  breathing  is  the  proper  and  only  sure  way  to  secure 
full  lung  expansion. 

Let  us  all  join  hands  and  preach  fresh  air;  vote  for  open  squares, 
endorse  roof  gardens,  have  adenoids  and  tonsils  removed,  and,  if  we 
are  w^illing  to  endorse  and  work  for  the  fresh  air  treatment  with  the 
same  zeal  and  enthusiasm  as  that  with  which  we  have  worked  for 
fresh  and  pure  milk,  our  results  will  be  as  great  a  success  as  has  been 
secured  by  our  milk  enthusiasts. 


CHAPTER  XI 


DENTITION. 


The  views  held  several  decades  ago,  concerping  the  part  which 
dentition  plays  as  a  causative  factor,  either  direct  or  indirect,  in  the 
diseases  of  children,  have  undergone  a  radical  change,  and  much 
found  in  the  earlier  literature  must  today  be  rejected.  Many  of  the 
^Titers  of  that  period  considered  the  eruption  of  the  milk-teeth  to 
be  influential  in  producing  nearly  all  of  the  diseases  which  attack 
children.  The  claim  was  made  that  at  least  25  per  cent,  of  deaths 
occurring  during  the  first  two  years  of  childhood  were  due  to  the 
cutting  of  the  temporary  teeth. 


Fig.  25. — Inferior  maxillary  bone  of  a  child  one  day  old;  portion  of  bone  removed  in 
order  to  show  the  dental  sacs,  a,  left  half  of  lower  jaw;  shows  the  sacs  of  the  milk- 
teeth,  of  the  first  permanent  molar,  and  of  the  permanent  incisor  and  canine  teeth; 
b,  shows  the  first  permanent  molar,  and  the  sacs  of  the  milk-teeth. 

Old-time  theories  and  superstitions  concerning  teething  still  exist 
among  the  laity,  both  the  well-to-do  and  the  poor,  and  the  physician 
today  is  often  summoned,  perhaps  too  late,  to  attend  children  seriously 
ill  with  gastro-intestinal  disorders,  or  suffering  from  dangerous  ner- 
vous afl^ections,  such  as  convulsions,  the  parents  believing  that  the 
illness,  being  due  to  teething,  is  of  comparatively  little  importance. 
It  is  obviously  the^duty  of  every  physician  to  correct  this  popular 
but  erroneous  belief  in  the  widespread  influence  of  dentition  as  a 
direct  cause  of  disease;  for,  until  this  is  accomplished,  hundreds  of 
children  will  annually  die  from  neglected  diseases — diarrheal  disorders 
especially — many  parents  believing  that  mild,  or  even  moderately 
severe,  diarrhea  during  the  period  of  teething  is  distinctly  beneficial. 


218 


DENTITION 


As  opposed  to  the  former  belief  that  all  infantile  disease  was  due  to 
teething,  it  is  interesting  to  note  that  some  of  the  most  advanced 
clinicians  of  toda>'  emphatically  deny  that  dentition  can,  in  itself, 
set  up  any  distinct  morbid  condition.  Teething,  they  claim,  is  simply 
a  physiological  process  that  is  normal  in  the  human  body,  and  there- 
fore should  not  be  regarded  as  a  pathologic  factor. 

]Many  of  these  physicians  admit  that  during  the  period  of  dentition 
there  exists  a  predisposition  to  illness,  and  I  am  quite  in  accord  with 
this  view.     After  careful  investigations,   all  recent  observers  agree 


Fig.  26. — The  milk-teeth  in  a  child  aged  about  four  years. 
are  seen  in  their  alveoli.      (Cryer.) 


The  permanent  teeth 


in _ ascribing  fewer  and  fewer  symptoms  to  dentition;  and,  from  the 
standpoint  of  both  the  safety  of  the  patient  and  the  reputation  of  the 
physician,  it  is  well  to  examme  the  child's  whole  body  carefully  before- 
making  a  diagnosis  of  "teething."  This  is  especially  important  when 
the  symptoms  are  not  local,  but  remote,  as  it  is  often  difficult,  espe- 
cially when  no  distinct  cause  other  than  teething  is  apparent,  to  give 
to  dentition  its  proper  causative  significance. 

Even  if  the  gums  are  tense  and  swollen,  and  no  other  adequate 
cause  can  be  detected,  it  is  not  wise  to  be  too  hasty  in  ascribing  to 
dentition  a  positive  causative  influence;  since  such  cases,  after  a  few 


DENTITION  219 

(lays,  oi'teii  clearly  show  their  i)iilm()iiary,  cerebral ,  or  other  ori<i!;iii, 
the  process  of  dentition  being  merely  coincident,  or,  at  the  most,  it 
intensifies  the  symptoms  and  does  not  produce  them. 

Dentition  occurs  in  that  period  of  life  when  physical  development 
is  most  rapid  and  functional  activity  highest.  The  nervous  system 
is  in  a  preparatory  condition;  the  follicular  apparatus  of  the  intes- 
tines is  rapidly  developing,  and  almost  all  of  the  organs  and  tissues 
of  the  body  are  undergomg  change.  During  infancy  and  early  child- 
hood the  mucous  membranes  are  especially  vulnerable  to  disease; 
hence  the  frequency  of  stomatitis  and  other  digestive  and  diarrheal 
disorders. 

If  we  bear  in  mind  that,  during  this  early  period  of  dentition,  the 
child  is  w^eaned,  and  is  commonly  given  food  more  or  less  unsuited 
to  its  digestion,  the  development  of  diarrhea  in  its  various  forms 
seems  obvious.  In  considering  the  frequency  with  which  dentition 
causes  or  complicates  disease,  the  attending  circumstances  must  be 
carefully  weighed,  and  cool  judgment  is  necessary. 

The  effects  of  teething  are  governed  largely  by  the  child's  physical 
condition.  If  healthy,  children  often  pass  through  this  critical  period 
without  any  symptoms  referable  to  the  eruption  of  the  teeth.  If 
they  are  weak,  rachitic,  or  suffering  from  malnutrition,  inherited 
syphilis,  scrofula,  or  a  neurotic  temperament,  either  inherited  or 
acquired,  the  period  of  teething  is  one  of  distinct  danger,  and  is  often 
accompanied  by  pyrexia,  with  heat,  swelling,  and  redness  of  the  gums, 
stomatitis,  and  gastro-intestinal  disorders. 

In  delicate  children  dentition  may,  and  often  does,  aggravate  the 
symptoms  of  any  existing  disease,  and  to  a  certain  extent  this  is  true 
also  of  breast-fed  healthy  infants.  Where  there  is  a  profound  con- 
stitutional disease,  either  inherited  or  acquired,  the  disorders  which 
appear  during  teething  may  be  traced  to  weakened  vitality  produced 
by  disease,  and  not  to  the  teething  per  se;  for  example,  children  who 
are  constitutionally  weak,  and  who,  on  the  slightest  febrile  irritation 
produced  by  the  erupting  teeth,  are  rendered  unable  to  digest  the 
food  best  suited  to  their  nourishment  when  well,  the  fever  having 
temporarily  weakened  their  digestive  powers. 

As  early  as  the  seventh  week  of  intra-uterine  life,  the  beginning 
formation  of  the  milk-teeth  can  be  detected.  Fig.  26  represents  the 
dental  sacs  exposed,  as  they  exist  in  the  lower  jaw  of  a  child  at  birth. 
Fig.  27  depicts  a  part  of  both  jaws  of  a  child  about  four  years  old,  and 
shows  the  relation  of  the  temporary  and  permanent  teeth. 

The  formation  of  the  hard  part  of  the  tooth  begins  quite  early, 
thin  caps  or  shells  of  dentin  being  found  on  all  milk-teeth  at  the  end 
of  the  fourth  month^of  fetal  life,  when  the  coating  of  enamel  begins  to 
be  deposited.  It  is,  therefore,  evident,  as  pointed  out  by  Forcheimer, 
that  the  process  of  teething  is  in  great  part  accomplished  before  the 
child  is  born. 

The  calcification  of  the  fangs,  and  the  increasing  size  of  the  tooth, 
forces  the  crown  toward  the  mouth,   and  perforation  of  the  gum 


220  DEXTITIOX 

follows.  Many  observers  claim  that  other  factors  are  concerned 
in  the  eruption  of  the  milk-teeth,  but  the  elongation  of  the  fang  is 
certainly  the  chief  one.  For  details  as  to  the  development  of  the 
teeth,  and  theories  concernmg  the  forces  that  are  operative  in  the 
advance  of  the  crowTi  to^-ard  the  gum,  the  reader  is  referred  to  works 
on  dental  stirgery. 

The  usual  time  and  order  of  eruption  are  as  follows:  The  two  lower 
central  mcisors  appear  at  the  age  of  six  or  seven  months;  the  tipper 
central  mcisors  between  the  seventh  and  ninth.  During  the  tenth 
month  the  upper  lateral  incisors  usually  erupt,  and  the  lower  lateral 
incisors  between  the  eleventh  and  twelfth.  ^Yell-developed  breast-fed 
infants  usually  have  cut  all  of  the  incisors  at  the  age  of  one  year. 
The  four  anterior  molars  appear  between  the  twelfth  and  sixteenth 
months;  the  canines  from  the  sixteenth  to  the  twentieth,  and  the 
entire  set  of  milk-teeth,  twenty  m  all,  should  have  erupted  by  the 
time  the  child  is  two  and  a  half  years  old. 

These  figures  represent,  however,  only  average  periods,  and  a 
delay  of  a  month  or  more  in  the  appearance  of  the  first  teeth,  or  even 
of  several  months  in  the  appearance  of  the  later  ones,  may  happen  in 
the  best-developed  and  most  healthy  children.  The  teeth  are  usually 
cut  in  groups  or  pairs,  a  considerable  period  mtervenmg  between  the 
eruption  of  each  group,  and  the  teeth  of  the  lower  jaw,  as  a  rule,  pre- 
ceding those  of  the  upper  by  a  few  weeks. 

This  normal  order  of  eruption  often  shows  variations,  and  the 
upper  incisors  may  appear  first,  especially  when  dentition  is  delayed. 
The  central  incisors  may  follow,  instead  of  preceding  the  lateral; 
the  posterior  molars  may  precede  the  canines,  or  the  anterior  molars 
may  even  be  the  first  to  erupt.  Rickets  is  commonly  fgund  in  cases 
where  the  teeth  appear  irregularly. 

iVbsorption  of  the  milk-teeth  begins  at  the  extremity  of  the  fangs, 
and  progresses  toward  the  crown,  the  teeth  disappearing  m  much  the 
same  order  as  they  appear.  The  fangs  being  absorbed,  the  crowm 
becomes  detached  either  by  the  advancing  permanent  tooth  or  by 
the  accidental  pressure  to  which  the  slightly  attached  tooth  is  neces- 
sarily subjected. 

Dentition  may  be  abnormal  either  in  being  premature  or  delayed; 
when  premattue,  it  is,  in  my  experience,  usually  easy.  Dentition 
beginning  at  five  months  is  not  uncommon,  and,  in  rare  cases,  the 
first  tooth  may  appear  at  sixteen  or  even  fourteen  weeks.  Henoch 
mentions  two  cases  of  premature  dentition  at  six  weeks  and  thirteen 
days  respectively;  but  such  cases  are  medical  curiosities. 

Occasionally  one  tooth,  and  even  two  teeth  have  been  noticed  at 
birth.  These  natal  teeth  are  usually  the  incisors  of  the  lower  jaw, 
and  if  poorly  formed,  consisting  largely  of  crown  with  little  or  no 
fang,  as  is  generally  the  case,  they  should  be  removed;  for,  if  allowed 
to  remain,  they  are  likely  to  mjine  the  mother's  nipple  and  the  frenum 
of  the  child's  tongue.  In  a  case  which  recently  came  under  my  notice, 
such  an  inj\n\v  to  the  mother's  breast  necessitated  the  removal  of  two 


DENTITION  221 

lower  natal  incisors.  Xatal  teeth,  if  fairly  well  formed  and  firmly 
attached,  should  certainly  not  be  interfered  with,  unless  they  cause 
distinct  disturbance  or  become  loose. 

Delayed  dentition  is,  however,  quite  common,  and  indicates  that 
the  physical  condition  is  below-  par.  In  this  connection  it  is  interest- 
ing to  note  that  acute  disease,  if  not  followed  by  marked  and  persis- 
tent constitutional  symptoms,  has  little  or  no  effect  upon  the  time  when 
the  teeth  erupt.  Artificially  fed  children,  how^ever,  usually  cut  their 
teeth  later  than  the  breast-fed,  and  a  delay  of  one,  or  even  two  months, 
is  in  such  children  not  unusual.  Cases  in  which  dentition  is  delayed 
until  the  twelfth  or  sixteenth  month  are  not  uncommon,  and  Jacobi 
reports  the  case  of  a  boy  who  had  cut  no  teeth  when  two  years  and 
ten  months  old. 

Imperfections  in  the  enamel  and  early  decay  are  quite  common  in 
cases  of  delayed  dentition,  and  are  due  to  the  fact  that,  the  constitu- 
tion being  below  par,  the  enamel  or  dentin  is  imperfectly  formed. 
This  imperfect  formation  of  enamel  and  dentin  and  early  decay  are 
regarded  by  Mr.  Hutchinson  as  in  some  cases  due  to  infantile  stoma- 
titis. Retarded  dentition  is  usually,  but  not  necessarily,  connected 
with  rachitis;  and,  while  delayed  dentition  points  strongly  to  rickets, 
it  must  be  borne  in  mind  that  the  two  conditions  are  not  alw^ays 
associated. 

Children  in  whom  dentition  is  delayed  should  undergo  a  thorough 
physical  examination  to  ascertain  whether  they  have  any  acquired 
or  inherited  disease.  The  diet,  hygiene,  clothing,  bathing,  and  general 
care  of  the  infant  should  be  carefully  looked  into.  For  internal  treat- 
ment, the  two  remedies  that  best  promote  dentition  are  cod  liver  oil 
and  iron.    All  local  measures  are  useless. 

Any  influence  which  rickets  may  have  upon  the  time  of  eruption 
depends  upon  the  age  at  which  distinct  rachitic  symptoms  develop. 
If  the  disease  does  not  manifest  itself  until  the  end  of  the  first  year, 
the  earliest  teeth  may  appear  at  the  normal  period,  and  a  long  interval, 
during  which  dentition  is  arrested,  may  follow^  the  symptoms  of  rickets. 
Teeth  that  appear  during  the  rachitic  period  are  usually  deficient 
in  enamel,  and  decay  early. 

When  dentition  is  delayed,  many  of  the  symptoms  usually  attributed 
to  teething  are  caused  by  the  associated  condition,  i.  e.,  rachitis,  with 
its  inevitable  malnutrition.  In  this  connection  Finlayson  says: 
"The  diagnosis  of  teething  diverts  the  mind  of  every  one  concerned 
from  the  vital  points  of  food,  air,  and  hygiene;  the  processes  leading 
up  to  rickets  are  largely  under  control,  even  in  the  cases  of  those  who 
are  comparatively  poor." 

Occasionally  the  full  number  of  milk-teeth  does  not  appear.  This 
may  be  owdng  to  a  family  peculiarity,  since  the  influence  of  heredity 
can  often  be  traced  in  the  history,  or  it  may  be  the  consequence  of 
destruction  of  the  tooth-germ.  Absence  of  one  or  more  of  the  milk- 
teeth  apparently  has  no  effect  upon  the  number  or  appearance  of  the 
permanent  teeth,  notwithstanding  the  fact  that  teeth  more  often  fail 


222  DEXriTIOX 

to  appear  in  the  second  than  in  the  first  dentition,  an  excess  in  the 
number  of  milk-teeth  being  more  common  than  a  deficiency.  An 
extra  incisor  is  probably  the  most  frequent  form  of  this  abnormality. 
Cases  of  multiple  dentition,  i.  e.,  the  appearance  of  more  than  two 
sets  of  teeth,  have  been  reported. 

Irregularity  in  the  position  of  the  teeth  is  more  common  in  the 
permanent  than  in  the  temporary  set,  but  is  usually  limited  to  a  slight 
overlapping  of  the  incisors  or  a  twisting  of  the  canines  on  their  axes. 
This  malposition  is  mainly  due  to  a  disproportion  between  the  size 
of  the  jaw  and  the  space  required  for  the  developing  teeth,  the  jaw 
usually  being  undersized.  It  is  claimed  that  rickets  favors  this  lack 
of  development  of  the  maxillary  bones. 

By  almost  continuous  pressure  upon  the  upper  incisors,  thumb- 
sucking  may  cause  a  characteristic  deformity.  Vigilance  on  the  part 
of  the  mother  or  nurse,  and,  if  necessary,  binding  the  hand  in  a  splint, 
or  wrapping  the  thumb  in  a  small  bandage  saturated  with  some  harm- 
less but  intensely  bitter  preparation,  will  usually  correct  this  injurious 
habit. 

Lip-sucking  is  another,  but  less  common,  cause  of  depression  of 
the  lower  incisors.  It  consists  in  pressing  the  upper  incisors  against 
the  lower  lip  and  thus  forcing  the  lower  lip  against  the  lower 
incisors. 

The  teeth  may  be  poorly  formed,  in  that  either  their  structure 
or  their  actual  shape  is  defective.  Deficiency  in  lime-salts  and  imper- 
fections in  the  enamel,  as  shown  by  pigment  spots,  furrows,  or  pittings, 
are  powerful  predisposing  causes  to  early  decay,  which  can  be  averted 
only  by  cleanliness  and  watchful  care. 

Hutchinson's  teeth  are  characterized  by  deforniity/of  the  upper 
central  incisors,  the  cutting  edges  of  which' are  notched  and  crescentic 
in  shape,  owing  to  changes  in  the  early  formation  which  are  due  to 
inherited  syphilis.  This  notched  appearance  is  positively  significant 
of  inherited  syphilis  only  when  found  in  the  permanent  teeth;  in  the 
milk-teeth  it  often  has  no  special  significance.  In  inherited  syphilis 
both  sets  of  teeth  may  be  aft'ected  similarly. 

Teeth  of  poor  shape,  often  showing  deep  fissures,  offer  favorable 
sites  for  the  retention  of  secretions  which  may  rapidly  become  the 
breeding-ground  of  countless  microorganisms,  and  thus  predispose 
to  caries.  Imperfections  in  the  structure  of  the  milk-teeth  usually 
indicate  lowered  vitality  or  a  diseased  state  of  the  system  during 
intra-uterine  or  early  infantile  life. 

As  regards  the  role  of  dentition  in  producing  definite  symptoms  or 
conditions,  it  has  already  been  pointed  out  that  the  first  duty  of  the 
physician  is  to  examine  the  child  thoroughly  in  order  to  determine 
whether  the  symptoms  may  not  be  due  to  some  cause  other  than 
teething.  The  family  and  the  personal  history  of  the  little  •  patient 
should  always  be  elicited,  the  latter  including  such  facts  as  normal  or 
difficult  delivery,  the  method  of  feeding,  the  age  at  which  dentition 
began,  and  the  history  of  all  preceding  diseases. 


DENTITION         '  223 

Restlessness,  peevishness,  disturbed  sleep,  and  moderate  fever  are 
symptoms  commonly  met  with  in  children  during  the  teething  period. 
It  will  often  be  impossible,  even  after  the  most  careful  physical  exam- 
ination, to  account  for  their  occurrence  unless  we  accept  dentition 
as  a  cause;  but  the  fact  that  these  symptoms  are  much  more  common 
in  weak  and  sickly  infants  than  in  the  healthy,  and  that  they  do  not 
accompany  the  eruption  of  every  tooth  or  group  of  teeth,  confirms 
the  belief  that  dentition  may  occasionally  produce  such  symptoms  in 
a  healthy  child,  and  very  frequently  causes  them  in  those  whose  powers 
of  resistance  are  weakened  by  acquired  disease  or  hereditary  taint. 

Drooling,  which  is  said  to  precede  teething,  and  to  result  from  reflex 
stimulation  of  the  salivary  glands,  is,  in  my  opinion,  mainly  due  to 
the  normal  establishment  of  the  secretion  of  these  glands,  and  merely 
betokens  a  stage  in  the  development  of  the  digestive  system  of  which 
the  salivary  glands  constitute  an  important  part. 

Biting  of  the  fingers  or  of  any  hard  substance  that  can  be  carried 
to  the  mouth  is  common  during  dentition,  but  it  is  due  to  the  fact 
that  an  infant  naturally  carries  everything  to  its  mouth  rather  than 
to  pain  or  tenderness  of  the  gum.  It  expresses  mild  uneasiness  or 
/itching  of  the  gums,  not  actual  pain,  since  neither  pain  nor  tenderness 
would  be  relieved  by  rubbing  or  biting  on  hard  substances.  A  healthy 
child  is,  when  awake,  almost  always  in  active  motion,  and  the  move- 
ments of  the  muscles  of  mastication  may  be,  and  probably  are,  often 
but  a  part  of  its  general  muscular  activity. 

In  a  well-developed,  healthy  baby  the  gums  are  of  a  pale  pink 
color,  and  change  little  in  appearance  except  that  they  become  dis- 
tinctly elevated  as  the  tooth  approaches  the  surface.  Occasionally 
there  is  considerable  redness  as  well  as  heat,  and  in  such  cases  incision 
is  followed  by  a  slight  oozing  of  dark-colored  blood.  It  seems  quite 
improbable  that,  in  this  portion  of  the  gum  which  lies  immediately 
over  the  advancing  tooth,  there  can  be  any  severe  pain,  since  it  is 
usually  paler  in  color  than  the  surrounding  similar  tissue,  or,  at  most, 
is  only  occasionally  slightly  congested.  It  is  much  more  reasonable 
to  believe  that  if,  as  is  true,  the  sensitive  pulp  and  bony  fang  are 
absorbed  without  pain,  the  small  portion  of  the  gum  overlying  the 
advancing  crown  will  be  similarly  disposed  of. 

It  is  claimed  that  dentition  is  a  common  cause  of  gingi\'itis  and 
catarrhal  stomatitis;  but  these  conditions  are  rarely,  if  ever,  found 
in  healthy,  breast-fed  infants  if  the  oral  mucous  membrane  has  been 
kept  clean.  When,  in  bottle-fed  babies,  the  care  of  the  bottles  and 
nipples  and  of  the  mouth  of  the  child,  as  is  pointed  out  m  the  chapter 
on  Infant  Feeding  (page  183),  has  been  neglected,  gingivitis  and 
stomatitis  are  of  coramon  occurrence.  They  are  due,  however,  not 
to  dentition,  but  to  carelessness  on  the  part  of  the  attendants.  The 
irritation  occasionally  produced  by  the  crown  of  the  milk-tooth  at 
the  time  of  its  detachment  may,  however,  be  sufficient,  if  strict  clean- 
liness is  not  observed,  to  produce  stomatitis  or  even  local  ulceration. 

On  slight  exposure  the  bronchial  mucous  membrane  of  children 


224  DENTITION 

is  easily  excited  to  a  mild  degree  of  inflammation,  and  it  is  a  well- 
known  fact  that  between  the  ages  of  one  and  three  years  bronchial 
and  pulmonary  diseases  are  extremely  common.  Personally,  I  have 
never  been  able  to  trace  any  connection  between  these  diseases  and 
dentition. 

The  skin  of  a  child  is  so  delicate  and  so  easily  irritated  that  an 
explanation  for  various  skin  affections  has  naturally  been  sought  in 
dentition,  and  its  etiologic  influence  sturdily  maintained.  Lack  of 
cleanliness,  unsuitable  food,  digestive  disturbances,  improperly  given 
baths,  and  too  tight  clothing,  also  inherited  and  acquired  disease,  are 
all  powerful  factors  in  causing  skin  diseases  in  children.  When  these 
causes  are  carefully  considered  there  can  be  no  reason  for  ascribing 
cutaneous  disease  to  dentition. 

Enlargement  of  the  submaxillary  lymphatic  glands  is  generally 
due  either  to  some  local  cause  in  the  mouth  which  is  probably  the 
result  of  lack  of  cleanliness,  or  to  one  of  the  forms  of  stomatitis.  In 
babies  who  suft'er  from  scrofula,  teething  may  occasionally  be  an 
exciting  factor;  but  in  healthy  little  ones  it  rarely  causes  any  marked 
glandular  enlargement. 

In  children  of  strumous  diathesis,  corneal  ulceration  is  occasionally 
met  with,  especially  during  the  eruption  of  the  upper  canines,  or  when 
the  canines  become  carious.  I  have  never  knowai  it  to  result  from 
dentition  in  a  healthy  child.  Conjunctivitis  is  said  to  be  one  of  the 
many  results  of  teething;  but  careful  examination  will  usually  demon- 
strate its  dependence  upon  some  other  cause;  and,  as  with  corneal 
ulcer,  I  have  never  seen  it  in  a  healthy  child  when  it  could  be  traced 
to  dentition. 

The  most  common,  and  also  the  most  dangerous,  fall^fcy  in  regard 
to  teething  is  the  belief  that  during  this  period  of  tooth-cutting  diarrhea 
is  not  only  harmless,  but  even  beneficial.  It  is  claimed  that  the  secre- 
tory activity  of  the  glandular  system  of  the  intestinal  tract  is  greatly 
stimulated,  and  normal  peristaltic  action  greatly  increased,  by  reflex 
irritation  transmitted  through  the  sympathetic  nervous  system  from 
the  gums  to  the  vagus.  It  has  also  been  maintained  that  diarrhea  is 
often  excited  by  the  large  quantities  of  saliva  swallowed,  this  secre- 
tion being  stimulated  by  the  irritation  of  the  approaching  teeth. 

Digestive  and  diarrheal  disorders  owe  their  origin  (as  is  pointed 
out  elsewhere  in  this  work)  to  entirely  dift'erent  causes,  and  I  am 
convinced  that  diarrhea  is  never  produced  in  a  healthy  child  by  teeth- 
ing alone.  When  a  child  suffers  with  diarrhea,  the  slight  irritation 
occasionally  present  from  teething  may,  by  increasing  the  fever  and 
restlessness,  aggravate  the  existing  gastro-intestinal  disturbance,  but 
is  not  sufficient  to  originate  this. 

Teething  has  been  regarded  by  many  as  a  not  uncommon  cause 
of  acute  purulent  otitis  media.  Such  a  conclusion  must,  however, 
be  based  upon  the  supposition  that  considerable  inflammation,  sup- 
puration, or  dental  caries  is  present.  If  either  one  of  these  conditioiis 
exists  it  may  cause  inflammation  of  the  ear;  but,  as  one  rarely  finds 


DENTITION  225 

more  than  a  slight  redness  or  blueness  of  the  gums,  it  appears  most 
unlikely  that  dentition  can  play  any  important  role  in  the  causation 
of  ear  disease.  In  the  past,  inflammation  in  the  external  auditory 
canal  has  been  ascribed  to  teething,  but  it  is  questionable  whether 
reflex  dental  irritation  is,  in  itself,  ever  sufficient  to  induce  this  con- 
dition. 

The  opinion  that  dentition  is  the  most  common  cause  of  infantile 
eclampsia  has  never  been  disputed  until  recent  years.  There  is  no 
doubt  that  a  considerable  number  of  all  cases  of  convulsions  in  children 
are  reflex  in  origin,  and  that  extremely  slight  causes  ma}',  in  neurotic 
children,  bring  on  eclampsia.  It  is,  however,  very  doubtful  whether 
dentition  jjer  se  ever  causes  convulsions  in  a  well-developed,  healthy 
child.    Certainly  no  such  case  has  ever  come  to  my  notice. 

It  has  been  claimed,  too,  by  prominent  clmicians,  that  dentition 
ma}',  in  peculiarly  nervous  children,  predispose  to  reflex  disturbances 
and  be  the  cause  of  convulsions,  but  recent  investigations  show  that 
this  must  be  rarely,  if  ever,  the  case.  Careful  study  will  usually 
disclose  some  more  potent  causative  factor. 

Caries  of  the  temporary  teeth  may  set  in  soon  after  their  eruption, 
and  is  most  commonly  observed  in  the  poorly  nourished  and  bottle-fed, 
or  those  whose  oral  cavity  is  not  kept  scrupulously  clean. 

Decay  proceeds  more  rapidly  in  the  temporary  than  in  the  per- 
manent teeth,  often  causing  severe  pain,  especially  when  liquids, 
either  hot  or  cold,  are  taken  into  the  mouth.  Temporary  relief  is 
usually  afforded  by  plugging  the  cavity  with  a  small  piece  of  cotton 
saturated  with  chloroform,  laudanum,  or  oil  of  cloves.  All  cavities 
should  be  filled  with  an  alloy  or  gutta-percha  in  order  to  relieve  the 
pain  and  preserve  the  teeth  until  the  time  when  Nature  intends  them 
to  be  absorbed. 

JMuch  can  be  done  by  cleanliness  to  preserve  the  temporary  teeth 
from  caries,  and  during  early  infancy  they  should  be  cleansed  ever}' 
morning  and  evening  with  a  soft  piece  of  linen  or  muslin  wet  in  sterilized 
water.  After  the  teeth  have  pierced  the  gum,  a  soft  tooth-brush 
should  be  used.  All  tartar  formation  should  be  at  once  removed 
from  the  teeth  by  gently  rubbing  them  with  a  tooth-pick  of  soft  wood 
dipped  in  powdered  pumice  stone. 

If  we  consider  teething  as  a  process  that  rarely  produces  marked 
symptoms  in  healthy  children,  and  a  factor  that,  in  delicate  or  sickly 
infants,  may  and  occasionally  does  indirectly  aggravate  symptoms 
resulting  from  the  child's  condition  or  some  disease,  we  cannot  con- 
sistently believe  in  any  treatment  for  dentition  yer  se.  Proper  diet, 
bathing,  clothing,  sleep,  and  hygiene  for  the  child,  and  the  prompt 
treatment  of  any  existing  disease  or  morbid  condition,  constitute 
the  treatment  of  dentition. 

If  we  believe  in  the  far-reaching  effects  of  dentition  as  a  cause  of 

disease,  lancing  of  the  gums  is  naturally  a  remedial  measure  of  great 

importance.    If,  on  the  other  hand,  we  do  not  believe  in  this  influence 

of  dentition  in  producing  disease,  lancing  is  uncalled  for,  usually  does 

15 


226  DENTITION 

no  good,  and  may,  by  diverting  the  attention  of  the  physician  away 
from  the  actual  cause  of  the  symptoms,  do  much  harm. 

It  rarely,  if  ever,  hastens  the  eruption  of  the  tooth  tln-ough  the  gum ; 
indeed,  through  the  resulting  scar,  it  probably  retards  the  onward 
progress  of  the  tooth.  Occasionally  by  relieving  the  congestion  in 
the  gum  overlying  the  advancing  tooth  it  may  be  of  temporary  service, 
owing  to  the  slight  loss  of  blood  which  follows.  The  physician  who 
carefully  examines  his  patients  has  little  use  for  the  gum  lancet. 


*   CHAPTER  XII. 
RICKETS. 

Rickets,  or  rachitis,  is  a  constitutional  disease  of  early  childhood 
caused  by  disordered  nutrition.  It  is  characterized  by  developmental 
changes  in  the  bones  and  cartilages  which  result  in  typical  deformities, 
also  by  changes  in  the  muscles,  ligaments,  nervous  system,  and  many 
other  parts  of  the  body. 

Etiology. — Rickets  is  essentially  a  disease  of  infancy,  therefore 
most  commonly  seen  in  children  under  two  years  of  age.  In  the 
majority  of  cases  it  appears  after  the  sixth  month,  although  it  may  be 
congenital,  and  it  never  occurs  after  the  skeletal  development  is  com- 
plete. The  children  of  the  poor  in  large  cities  are  especially  prone  to  the 
disease,  children  of  the  well-to-do  being  rarely  affected,  and  then  only 
lightly,  although  if  these  children  are  fed  on  proprietary  foods,  which 
usually  contain  an  excess  of  carboh\'drates  and  a  deficient  amount  of 
fat  and  proteins,  they  may,  and  often  do,  show  slight  or  marked 
rachitic  changes.    Rickets  is  most  uncommon  in  the  country. 

Lack  of  hygiene  is  one  of  the  principal  causes  of  the  disease,  and  in 
congenital  rickets  it  is  difficult  to  estimate  the  hereditary  influence 
when  both  mother  and  child  have  been  subjected  to  the  same  un- 
hygienic surroundings  and  lack  of  proper  nutrition.  The  health  of 
the  father  is  not  believed  to  exert  any  influence  upon  the  occurrence 
of  rachitis  except  in  cases  of  paternal  syphilis,  tuberculosis,  or  chronic 
alcoholism.  The  important  predisposing  factors  which  act  upon  the 
mother  during  pregnancy  are  alcoholism,  tuberculosis,  syphilis,  scanty 
nourishment,  lactation,  and  close  indoor  confinement. 

Faulty  nutrition  is  by  far  the  most  potent  factor  in  the  production 
of  rickets,  the  disease  being  especially  common  in  bottle-fed  infants. 
Nurslings,  as  a  rule,  rarely  show  more  than  the  milder  manifestations 
of  the  affection,  unless  lactation  is  unduly  prolonged  to  eighteen 
months  or  two  years,  or  the  mother  again  becomes  pregnant,  or  is 
attacked  by  some  chronic  wasting  disease  which  impoverishes  her 
milk.  The  diet  of  artificially  fed  babies  who  are  rachitic  is  usually 
too  rich  in  carbohydrates,  but  poor  in  fats  and  proteins;  and  the 
impoverished  milk  of  many  of  the  women  in  the  tenement  districts, 
if  analyzed,  would  be  found  to  have  a  low  protein  and  fat  content. 

Proprietary  foods  for  babies,  as  a  rule,  contain  an  excess  of  carbo- 
hydrates, but  are  deficient  in  fats  and  proteins,  and  rachitis  is  not 
uncommon  in  those  children  who  during  infancy  were  fed  on  one  or 
another  of  these  preparations,  or  exclusively  on  condensed  milk. 

It  appears,  on  the  whole,  that  rachitis  is  more  severe  and  develops 
much  more  readily  when  there  is  a  lack  of  fats  and  proteins  than  when 


228  RICKETS 

there  is  a  deficiency  in  fats  alone;  also  that  if,  in  addition  to  these 
errors  in  diet,  there  is  an  excess  of  carbohydrates,  rickets  is  even  more 
likely  to  result.  In  support  of  these  theories  that  certain  food  changes 
are  responsible  for  its  development,  may  be  cited  in  the  following 
observations : 

Bland  Sutton,  experimenting  with  lion  whelps  at  the  London 
Zoological  Gardens,  showed  that  if  they  w^ere  weaned  earh'  and  fed 
entirely  on  raw  meat  they  soon  became  rachitic,  and  that  the  rachitic 
changes  were  most  marked  when  an  excess  of  carbohydrates  was  given. 
If,  however,  a  diet  of  powdered  bones,  cod  liver  oil,  and  milk  was 
substituted,  they  quickly  recovered.  Chossat,  in  1842,  demonstrated 
by  animal  experimentation  that  rachitic  changes  appeared  in  the  bones 
when  lime  was  excluded  from  the  diet.  Heitzmann  claims  that  if 
lactic  acid  is  introduced  into  the  food  of  young  animals  rickets  will 
develop. 

But,  even  though  lactic  acid  forms  a  soluble  salt  when  it  unites 
with  the  calcium  in  the  bones,  thus  eliminating  lime  from  the  system, 
this  does  not  explain  the  various  other  abnormalities  in  the  bones 
which  are  observed  in  rickets.  Young  animals  fed  upon  a  strictly 
vegetable  diet  also  become  rachitic,  which  fact  further  emphasizes  the 
need  of  sufficient  fat  for  the  growing  osseous  system. 

In  all  the  foregoing  experiments,  whenever  rachitic  symptoms  and 
signs  de\'eloped,  these  could  be  made  to  disappear  by  so  altering  the 
diet  that  the  fats  and  proteins  were  increased  and  the  carbohydrates 
diminished  without  making  any  change  in  the  living  conditions ;  which 
seems  to  show  how  much  more  important  is  diet  than  hygiene  in  the 
etiology  of  rachitis.  Sex  has  no  influence  on  its  occurrence,  since  boys 
and  girls  are  alike  subject  to  the  disease. 

The  geographical  distribution  of  the  disease  has  been  quite  definitely 
worked  out;  and,  although  rickets  occurs  everywhere,  it  is  most 
common  in  the  temperate  zones,  the  majority  of  cases  being  observed 
in  large  cities.  It  is  more  prevalent  in  Great  Britain,  Germany, 
Russia,  and  Italy  than  in  the  United  States,  is  rare  in  the  tropics,  and 
infrequent  in  Iceland,  Greenland,  Denmark,  and  Norway. 

Nationality  and  race  are  also  important  factors  in  the  occurrence 
of  rachitis,  since  the  great  majority  of  cases  in  the  United  States 
are  seen  in  negroes  and  Italians.  Practically  all  negro  children  exhibit 
some  signs  of  rickets,  and  it  is  thought  that  the  change  of  climate  from 
a  southern  to  a  northern  latitude  may  be  largely  responsible  for  this; 
since,  on  the  whole,  the  diet  of  the  negro  does  not  differ  materially 
from  that  of  other  races  in  the  large  cities,  and  rickets  is  uncommon 
in  Africa. 

Illnesses,  such  as  chronic  gastro-intestinal  disorders,  may  precede 
rickets,  and  syphilitic  children  may  show  rachitic  changes;  but,  aside 
from  these  influences  which  so  impair  the  nutrition  that  the  child  can- 
not assimilate  sufficient  fats  and  proteins  for  the  needs  of  the  body, 
associated  diseases  have  but  little  bearing  upon  the  production  of 
rachitis  in  children, 


PATHOLOGY  229 

Most  cases  of  rickets  are  seen  diiriiii;'  tlic  winter  iiioiiths,  wliicJi  is 
thought  to  be  due  to  ch)se  confinement  and  lack  of  exercise  at  this 
season  of  the  year,  especially  among  the  poorer  classes.  Findlay 
demonstrated  in  animals  that  lack  of  exercise  alone  will  cause  rickets, 
even  when  plenty  of  fresh  air  is  provided. 

The  chief  cause  of  rachitis  is  now  universally  recognized  to  be 
faulty  diet;  and,  although  the  precise  way  in  which  rachitic  changes 
are  brought  about  is  not  clearly  understood,  there  is  little  doubt  that 
the  assimilation  of  calcium  salts  is  in  some  manner  interfered  wdth. 
Mircoli  attributes  rickets  to  the  action  of  ordmary  pyogenic  bacteria 
upon  the  bones  and  nervous  system. 

Pathology. — In  the  normal  child  the  bones  grow  longitudinally  by 
the  production  of  bone  in  the  cartilage  between  the  diaphysis  and  the 
epiphysis,  and  their  thickness  is  increased  by  the  production  of  bone 
by  the  inner  layer  of  the  periosteum.  In  rachitis,  however,  owing 
either  to  clironic  inflammation  or  simply  to  disorders  of  nutrition, 
this  process  of  growth  is  altered  and  becomes  abnormal,  inasmuch  as 
an  excess  of  cartilage  is  produced,  but  very  little  mineral  salts  are 
deposited,  which  completely  arrests  ossification. 

The  cells  produced  by  the  inner  layer  of  the  periosteum  also  fail  to 
ossify,  and  there  is  frequently  abnormal  absorption  of  the  medullary 
layers  of  bone  within  the  canal.  These  conditions  tend  to  produce  a 
much  softer  and  more  vascular  bony  structure  than  normal,  which, 
owing  to  the  lack  of  ossification,  is  very  flexible  and  weak.  The  bones 
of  these  children  sometimes  contain  twice  as  much  animal  as  mineral 
matter,  and  ossification  is  so  irregular  that  areas  of  bone  may  be 
found  scattered  throughout  the  cartilage  and  the  bony  parts  may  be 
infiltrated  by  islands  of  cartilage. 

Deformity  is  most  marked  in  the  long  bones,  because  of  lack  of 
ossification  in  the  external  layers  of  the  shaft  and  increased  bone 
absorption  in  the  medullary  cavity,  which  makes  the  bony  shaft  very 
thin.  The  increased  proliferation  of  cells  at  the  epiphysis  results  in  a 
most  constant  and  characteristic  change  in  the  form  of  the  bones, 
namely,  enlargement  of  the  ends  of  the  long  bones,  especially  notice- 
able at  the  wrists  and  ankles,  which  may  be  half  as  large  again  as 
in  normal  children.  Other  characteristic  enlargements  occur  at  the 
costal  ends  of  the  ribs. 

In  addition  to  these  bony  changes,  pigeon-breast  and  scoliosis  are 
common.  The  abnormal  shape  of  the  softened  bones  is  brought  about, 
for  the  most  part,  by  the  weight  of  the  body  w^hile  the  child  is  in  differ- 
ent attitudes,  and  is  most  marked  if  it  is  allowed  to  walk,  or  even  to 
sit  up  unsupported,  too  soon.  In  some  instances  the  bones  break 
instead  of  bending,  but  the  fracture  is  usually  of  the  green-stick 
variety. 

The  flat  bones  of  the  head  and  pelvis  exhibit  changes  somewhat 
like  those  found  in  other  bones  of  the  body.  The  external  surfaces 
are  soft,  porous,  and  extremely  vascular.  At  the  centres  of  ossification 
are  produced  large  bosses  which  are  soft  and  spongy.    In  other  areas 


230  RICKETS 

of  the  fiat  bones  there  may  be  but  a  thin  membrane  in  place  of  bony 
structure.  When  longitudinal  section  of  a  large  bone  is  made,  the 
epiphyseal  junction  may  be  outlined  by  its  bluish  color;  it  is  very 
vascular,  softer  than  normal,  and  reveals  attempts  at  calcification 
nearest  the  head  of  the  bone.  The  amount  of  cartilage  at  the  end  of 
each  long  bone  is  four  or  five  times  greater  than  normal,  and  the 
centres  of  ossification  are  larger  and  more  vascular  than  normal. 

On  observing  a  cross-section  of  the  shaft  of  a  long  bone,  the  inner 
layers  are  found  to  be  quite  firm,  and  most  of  the  decalcification  is 
in  the  external  layers  of  the  shaft.  The  medullary  cavity  appears  to 
be  more  porous  than  normal,  and  more  vascular.  If  a  section  is  made 
through  a  boss  on  one  of  the  flat  bones,  it  is  found  to  be  soft,  spongy, 
and  highly  vascular,  and  the  ordinary  arrangement  of  the  outer  and 
inner  tables  of  the  skull,  separated  by  the  intervening  diploe,  is  lost. 

Aside  from  the  changes  in  the  osseous  tissues,  there  are  also  certain 
pathological  changes  in  the  viscera.  Among  these  enlargement  of 
the  spleen  is,  perhaps,  the  most  common,  and  is  the  result  of  hyper- 
plasia of  the  splenic  pulp  and  follicles.  In  addition  to  an  increase  in  the 
connective  tissue  within  the  spleen,  the  capsule  is  also  thickened  by  a 
fibrous  perisplenitis. 

When  a  section  of  the  spleen  is  examined  microscopically,  atrophic 
changes  can  be  detected  in  the  Malpighian  bodies,  the  arterial  blood- 
vessel walls  show  thickening,  and  the  whole  organ  looks  pale  and 
anemic.  In  more  than  50  per  cent,  of  children  with  rickets  an  enlarged 
spleen  can  be  demonstrated;  in  exceptional  cases  it  may  be  more  than 
double  the  normal  size.  Enlargement  of  the  liver  is  less  frequently 
observed,  not  being  so  marked  as  splenic  enlargement,  with  which  it 
may  or  may  not  be  associated.  It  is  also  due  to  simple  hyperplasia 
of  the  connective  tissue. 

There  are  hyperplastic  changes  in  the  lymph  nodes  of  the  body 
which  render  them  distinctly  palpable;  but  they  do  not  become  as 
large  as  in  syphilis  and  tuberculosis.  The  muscles  of  these  children 
show  a  lack  of  tonicity,  and  imperfect  and  defective  striation  due  to 
lack  of  nutrition  and  disuse. 

The  microscope  reveals  in  the  sectioned  muscle  excessive  nuclei, 
a  distortion  of  the  longitudinal  striae,  and  thin  imperfect  fibers.  When 
deformity  of  the  chest  is  extreme,  the  lungs  are  often  furrowed  by  the 
pressure  of  the  deformed  ribs;  the  pressure  also  causes  partial  or 
complete  atelectasis  in  these  areas,  and  a  compensatory  emphysematous 
condition  in  the  adjacent  lung  tissue.  Acute  and  chronic  bronchitis 
and  prolonged  bronchopneumonia  are  also  common  findings  in  the 
respiratory  tract,  owing  to  the  general  debility  from  malnutrition. 

The  mucosa  of  the  stomach  and  intestines  usually  gives  evidence  of 
more  or  less  chronic  catarrhal  changes,  and  a  mild  degree  of  dilatation 
not  uncommonly  results  from  the  atonic  condition  of  the  gastric  and 
intestinal  musculature.  Mild  hydrocephalus  is  sometimes  observed 
in  rachitic  children;  but  the  exact  relation  between  these  two  con- 
ditions is  not  clear.     Hyperplasia  of  the  brain  has  also  been  described 


TERMINATION  231 

in  coiiiiectioii  witli  rickets,  but  its  relation  and  significance  are  as  yet 
undetermined  and  obscure. 

Histology. — Upon  microscopical  examination  of  the  end  of  a  long 
bone  we  see,  next  to  the  hyaline  cartilage,  a  layer  of  proliferating 
cartilage  cells  and  a  highly  vascular  matrix  in  disordered  arrangement. 
Beyond  this  are  columns  of  hypertrophied  cartilage  cells  in  regular 
order,  then  a  zone  of  calcification,  finally  a  zone  of  ossification. 

Rachitic  changes  are  most  prominent  in  the  layer  of  proliferating 
cartilage  cells  and  in  the  columnar  area,  the  proliferating  layer  being 
thickest  in  fetal  rickets,  and  the  layer  of  columnar  arrangement 
thickest  in  extra-uterine  life.  Because  of  its  excessive  thickness,  the 
epiphysis  is  compressed  and  bulges  laterally,  causing  the  typical 
rachitic  deformity.  The  increase  in  cartilage  cells  and  in  vascularity, 
which  is  most  marked  in  the  columnar  layer,  causes  the  characteristic 
changes  in  these  two  zones,  while  the  area  of  ossification  shows  deficient 
calcification,  and  the  cartilaginous  areas  jutting  into  it  make  the  out- 
line of  the  zone  of  ossified  cells  broad  and  irregular,  instead  of  narrow 
and  sharply  defined. 

The  periosteum  is  greatly  thickened,  much  more  vascular  than  nor- 
mal, and  strips  readily  from  the  bone,  revealing  beneath  it  the  exces- 
sive cell  proliferation  which  sometimes  causes  such  great  thickening 
of  the  bone  that  in  places  the  medullary  cavity  is  impinged  upon. 
The  changes  in  the  flat  bones  are  practically  the  same  as  those  in  the 
long  bones,  and  consist  chiefly  of  increased  cell  production,  increased 
vascularity,  and  imperfect  calcification. 

They  are  even  more  pronounced  in  the  spongy  bones;  and,  in 
addition  to  these  changes,  the  spongy  bones  contain  large  medullary 
spaces  filled  with  bloodvessels  and  cellular  connective  tissue,  and 
occupying  the  spaces  of  the  eroded  bony  trabeculse. 

Termination. — The  rachitic  process  usually  terminates  in  from  three 
months  to  a  year,  when  ossification  sets  in,  as  is  evident  from  the 
appearance  of  lime  salts  in  the  lamellae  of  the  osteoid  tissue;  in  some 
places  there  is  a  direct  transformation  of  cartilage  into  bone.  iVt  the 
same  time  excessive  cell  proliferation  at  the  epiphysis  and  on  the 
inner  surface  of  the  periosteum  ceases,  and  the  amount  of  absorp- 
tion in  the  medullary  cavity  decreases,  the  bones  becoming  less 
vascular. 

Calcification  is  accompanied  by  contraction  and  condensation  of  the 
spongy  bony  structure,  so  that,  on  complete  recovery,  the  bones  are 
often  harder  and  denser  than  normal.  This  shrinkage  in  the  spongy 
bone  structure  decidedly  reduces  the  degree  of  deformity  from  the 
enlarged  and  prominent  epiphyses  of  the  long  bones.  The  bosses  on 
the  skull  become  smaller,  and  the  beading  of  the  ribs  imperceptible, 
until,  finally,  all  traces  of  these  rachitic  changes  tend  to  disappear. 

The  curvatures  and  deformities  of  the  spine,  pelvis,  and  lower 
extremities  due  to  the  weight  of  the  thorax  are  also  lessened  to  some 
degree ;  but  when  these  deformities  have  been  marked  and  ossification 
has  occurred,  permanent  signs  of  rachitis  usually  remain. 


232  RICKETS 

Symptoms. — The  onset  of  rickets  is  very  gradual.  In  some  cases 
a  moderate  degree  of  gastro-intestinal  catarrh  precedes  the  actual 
manifestations.  Constipation  is  a  common  feature,  owing  to  the 
atonic  state  of  the  intestinal  muscles;  but,  in  some  instances,  there 
may  be  alternating  attacks  of  diarrhea  as  a  result  of  chronic  irritation 
of  the  colon  by  the  hard,  dry  stools.  The  appetite  is  often  unimpaired, 
and  may  even  be  excessive.    Vomiting  is  uncommon. 

These  infants  are  restless  and  irritable  during  the  day  and  sleep 
poorly  at  night,  tossing  about  in  bed  and  waking  at  frequent  intervals. 
There  may  be  slight  fever  at  the  onset  of  rickets,  but  any  high  elevation 
of  temperature  during  the  course  of  the  disease  should  cause  the 
physician  to  suspect  some  intercurrent  infection.  Excessive  perspira- 
tion about  the  head  and  neck,  especially  at  night,  is  one  of  the  earliest 
and  most  characteristic  symptoms,  and  is  an  invariable  feature  of  the 
disease,  often  continuing  for  months.  This  symptom  is  seldom  over- 
looked, since  the  pillow  upon  which  the  rachitic  child  sleeps  is  always 
wet,  while  the  rest  of  the  bedclothing  is  dry.  Head  rolling  is  observed 
in  many  cases,  and  these  children  have  a  habit  of  grinding  their  teeth, 
which  sj'^mptom,  however,  is  not  peculiar  to  rickets  alone. 

Chronic  catarrhal  rhinitis  and  pharyngitis,  attacks  of  acute  and 
chronic  bronchitis,  and  acute  colds  are  common  in  rachitic  children. 
Some  observers  believe  that,  in  addition  to  the  influence  of  their  lowered 
vitality  which  w^ould  predispose  them  to  such  affections  of  the  upper 
respiratory  tract,  these  children  also  acquire  acute  colds  and  bron- 
chitis from  sleeping  constantly  on  a  wet  pillow  and  lying  uncovered 
in  bed,  the  bed-covers  being  kicked  off  in  their  restlessness. 

During  the  day  rachitic  children  seem  languid  and  indisposed  to 
move  about,  or  to  be  picked  up  and  fondled.  This  has  been  attributed 
to  tenderness  throughout  the  body,  which  is  sometimes  quite  marked 
over  bony  •  surf  aces  and  certain  groups  of  muscles. 

The  general  appearance  of  rachitic  children  differs  somewhat;  but, 
as  a  rule,  they  are  pale  and  look  anemic.  Although  they  frequently 
appear  to  be  well  nourished,  their  flesh  is  fat  and  flabby,  and  their 
muscular  tissue  has  but  little  tonicity.  In  exceptional  cases  of  rickets, 
the  child's  complexion  may  be  very  good  and  the  general  health 
apparently  unimpaired ;  in  still  another  class  of  cases  the  rachitic  child 
may  be  thin  and  wasted,  presenting  the  typical  picture  of  marasmus. 

The  blood  shows  no  characteristic  changes  aside  from  simple  anemia. 
The  hemoglobin  content  is  low,  ranging  from  40  to  60  per  cent.; 
the  number  of  red  cells  varies  but  little  from  normal.  The  total  number 
of  leukocytes  is  increased,  but  there  is  no  notable  increase  of  any 
particular  variety  of  white  cells. 

The  urine  presents  no  characteristic  changes  which  would  suggest 
rickets,  but  the  calcium  salts  may  be  decreased.  Heitzmann  claims 
that  there  is  an  excess  of  lactic  acid  and  phosphates  in  the  urine,  and 
some  observers  are  inclined  to  believe  that  these  phosphates  are  being 
excreted  in  abnormally  large  quantities  instead  of  being  utilized  in 
bone  formation. 


EARLY  PHYSICAL  SIGNS  233 

Tlie  mucous  meml)ranes  of  the  body  are  pale  and  uudernourished, 
conscqueutly  the\'  readily  become  iuflamed  from  tri\  ial  causes,  such  as 
slight  indiscretions  in  diet,  and  moderate  changes  in  the  atmosphere 
or  climate.  This  inflammation  is  apt  to  pursue  a  chronic  and  pro- 
tracted course  rather  than  an  acute  one. 

Although  there  are  no  lesions  of  the  nervous  system,  yet  neurotic 
symptoms  are  quite  common  and  numerous  in  rachitis.  The  view  is 
held  that  these  manifestations  are  simply  a  result  of  the  impoverished^ 
condition  of  the  nervous  system,  in  common  with  all  other  tissues  of 
the  body.  Rachitic  children  are  all  neurotic,  and  the  normal  stability 
of  the  nervous  system  is  retarded  until  a  later  age  than  in  the  healthy 
child.  Baldness  at  the  occiput  is  often  observed  in  rachitic  infants, 
and  is  due  in  large  measure  to  the  constant  tossing  of  the  head  to 
and  fro  upon  the  pillow. 

Muscular  spasms  are  common,  and  may  take  the  form  of  laryngismus 
stridulus,  nystagmus,  tetany,  or  convulsions.  There  is  also  increased 
susceptibility  and  response  to  reflex  irritation.  Laryngospasm  and 
tetany  are  rarely  seen  in  other  than  rachitic  children,  and  rickets  is 
one  of  the  most  common  predisposing  causes  of  convulsions.  Nervous 
manifestations  are  most  marked  in  young  babies,  and  the  liability  to, 
and  severity  of,  the  symptoms  seem  to  depend  more  upon  the  age 
of  the  child  than  upon  the  severity  of  the  rachitic  process.  As  a  result, 
convulsive  seizures  are  most  common  before  the  second  year,  and  are 
often  excited  by  gastro-intestinal  disturbances,  by  reflex  irritability, 
or  by  the  action  of  toxins  absorbed  from  the  alimentary  tract. 

Dentition  in  rachitic  children  is  usually  delayed,  and  is  accompanied 
by  gastro-intestinal  disturbances,  which  in  large  part  are  due  to  the 
lowered  vitality  of  the  alimentary  mucosa;  they  sometimes  prove 
quite  serious.  The  first  teeth  may  be  cut  at  any  time  from  the  sixth 
to  the  eighteenth  month,  and,  although  dentition  is  late,  when  the 
teeth  do  erupt,  they  are  well  developed  and  do  not  decay  readily. 
This  is  in  sharp  contrast  to  dentition  in  syphilitic  infants,  in  whom  the 
teeth  appear  very  early,  but  are  poorly  developed,  and  quickly  decay. 

Early  Physical  Signs  of  Rickets. — The  earliest  and  most  typical  sign 
of  rickets  is  the  rachitic  rosary,  which  is  formed  by  the  enlarged  and 
widened  epiphyses  of  the  ribs  at  the  costochondral  junction.  The 
nodules,  or  beads,  thus  formed  are  most  prominent  at  the  fifth  and 
sixth  ribs,  and  it  is  here  that  they  may  be  first  detected.  They  can 
practically  always  be  felt  by  the  examining  fingers,  and  in  exceptional 
cases  are  distinctly  visible,  attaining  the  size  of  small  marbles.  When 
there  is  marked  thoracic  deformity,  beading  is  often  observed  on  the 
posterior  surface  of  the  anterior  chest  wall,  due  to  the  green-stick 
fractures  which  take  place  near  the  posterior  angles  of  the  ribs.  The 
ribs  in  these  cases  johi  the  cartilage  at  an  angle,  instead  of  end  to  end, 
and  there  is  partial  or  complete  dislocation  of  the  bony  rib  backward, 
so  that  frequently  when  posterior  beading  exists  there  is  no  beading 
on  the  external  surface  of  the  chest.- 

The  rachitic  rosary  can  rarely  be  detected  before  the  third  month, 


234 


RICKETS 


and  tends  to  diminish  in  size  under  proper  treatment  or  when  the 
disease  terminates  spontaneonsly,  so  that  there  is  scarcely  a  trace  of 
these  prominences  after  the  fifth  year,  and  they  are  not  perceptible 
in  adults. 

Craniotabes,  which  is  an  early  rachitic  sign,  is  a  softening  of  the 
cranial  bones  and  the  formation  of  thin  spots  from  pressure  within 
the  skull  as  well  as  from  external  pressure.  It  is  on  the  posterior 
portion  of  the  parietal  bones  and  on  the  occipital  bone  that  most  of 
these  thin  areas  are  found,  for  this  part  of  the  skull  is  most  frequently 
subjected  to  pressure  when  the  child  is  lying  down.    They  are  most 


Fig.  27. — Rachitis. 


numerous  about  the  lamboidal  suture,  seldom  appearing  on  the  frontal 
bones  in  the  region  of  the  coronary  suture.  They  are  sometimes  an 
inch  in  diameter,  and  several  may  be  found  on  the  skull  at  one  time. 
To  detect  them,  light  pressure  should  be  made  upon  the  skull  in 
a  direction  away  from  the  sutures.  When  an  area  is  pressed  upon, 
a  parchment-like  crackling  sensation  is  transmitted  to  the  fingers. 
Craniotabes  rarely  appears  in  infants  who  develop  rickets  after  the 
sixth  month,  and  it  is  much  more  marked  in  children  who  suffer  from 
both  congenital  syphilis  and  rickets  than  in  those  who  have  congenital 
syphilis  alone. 


DEFORMITIES  235 

Racfiitic  Deformities. — The  head  of  a  rachitic  child  appears  to  be 
larger  than  normal;  but  this  is  often  due  to  the  diminished  size  of  the 
facial  bones,  and  to  the  disproportion  between  the  head  and  the  rest 
of  the  body.  In  severe  cases  there  may  be  an  actual  increase  in  the 
circumference  of  the  head  which  is  due  to  abnormally  thick  cranial 
bones,  to  cranial  bosses,  or  to  hyperostoses.  These  hyperostoses  cause 
a  prominence  of  the  frontal  and  parietal  eminences  which  results  in 
the  typical  square  broad  forehead.  When  the  bosses  are  numerous 
they  sometimes  produce  furrows  along  the  line  of  the  coronal,  sagittal, 
and  frontal  sutures,  thus  forming  the  hot-cross-bun  type  of  skull. 

The  occiput  is  flattened  by  pressure,  the  crow^n  of  the  skull  is  flat 
rather  than  vaulted,  and  these  flattened  surfaces  together  with  the 
square  broad  forehead  give  the  skull  a  cuboid  rather  than  a  globular 
appearance.  The  anterior  fontanelle  is  very  late  in  closing,  and  may 
remain  open  until  the  second  or  third  year. 

A  faint  systolic  murmur  may  sometimes  be  heard  if  the  ear  is  placed 
directly  over  the  anterior  fontanelle ;  but  this  feature  is  of  no  diagnostic 
importance,  since  it  is  found  in  other  conditions  in  which  the  fontanelle 
has  failed  to  close.  The  closure  of  the  other  fontanelles  is  also  delayed, 
and  the  sutures  of  the  skull  may  not  completely  unite  until  after  the 
first  or  second  year. 

The  superficial  veins  of  the  scalp  are  enlarged,  prominent,  and  dis- 
tinctly visible.  The  hair  is  scant,  its  growth  being  retarded,  and  it  is 
worn  away  from  the  back  and  sides  of  the  head  by  friction  and  sweat- 
ing. The  upper  jaw  of  the  rachitic  infant  is  unusually  long  ^d 
narrow,  while  the  anterior  portion  of  the  lower  jaw  is  broader  and 
higher  than  normal,  and  curves  rather  sharply  at  the  site  of  the  canine 
teeth,  which  gives  it  a  square  and  angular  appearance. 

The  Chest. — In  addition  to  the  characteristic  deformity  known  as  the 
rachitic  rosary,  the  ribs  present  certain  curvatures  due  to  atmospheric 
pressure,  one  of  which  is  at  the  junction  of  the  dorsal  and  lateral 
portions  of  the  thorax,  and  the  other  is  located  anteriorly  where  the 
ribs  curve  toward  the  sternum.  A  lateral  flattening  is  thus  produced, 
which  extends  from  the  second  rib  to  the  hypochondrium  along  the 
line  of  the  costochondral  articulations.  This  flattening  lessens  the 
transverse  diameter  of  the  chest  and  causes  the  sternum  to  bulge,  thus 
forming  the  so-called  ingeon-  or  chicken-breast. 

The  anteroposterior  diameter  of  the  chest  is  increased.  The  thorax 
is  narrowed  at  the  clavicles,  but  flares  outward  below,  giving  rise  to  the 
so-called  funnel  chest.  This  widening  of  the  costal  angle  at  the  tip  of 
the  sternum  is  due  to  the  pressure  of  the  liver  and  spleen.  It  is  most 
marked  on  the  right  side  owing  to  the  presence  of  the  liver.  There  is 
also  formed  at  the  upper  level  of  the  liver,  stomach  and  spleen  a 
transverse  furrow,  known  as  the  rachitic  girdle,  or  Harrison's  furrow, 
which  is  produced  by  eversion  of  the  lower  thorax.  It  is  more  apparent 
on  inspiration,  since  this  portion  of  the  chest  wall  does  not  retract. 

These  deformities  of  the  chest  are  rarely  severe  in  uncomplicated 
cases  of  rickets,  but  are  exaggerated  when  the  respiration  is  obstructed 


236  RICKETS 

by  enlarged  tonsils  and  adenoids,  also  in  children  with  chronic  bron- 
chitis. In  some  rachitic  children  the  sternum  is  depressed  instead  of 
prominent. 

In  mild  cases  of  rickets  the  spine  is  normal;  but  in  many  well- 
developed  rachitic  children  there  is  kyphosis  in  the  dorsolumbar  region, 
which  extends  from  the  middorsal  vertebrse  to  the  sacrum.  This  is 
due  not  only  to  the  rachitic  process  in  the  bodies  of  the  vertebrse,  but 
is  also  induced  by  the  laxness  of  the  vertebral  ligaments.  It  is  most 
marked  when  the  child  is  held  in  the  arms,  but  can  be  made  to  disappear 
if  the  child  is  suspended  by  the  feet  or  laid  upon  its  belly  with  the  legs 
extended.  This  sign  is  an  important  point  in  the  differentiation  of 
rickets  from  Pott's  disease. 

Lateral  curvature  is  rare,  but  when  a  child  under  three  years  of 
age  develops  this  condition  it  is  almost  always  of  rachitic  origin. 
Lordosis  is  also  uncommon,  but  may  appear  in  association  with 
deformity  of  the  pelvis.  Spinal  curvatures  and  kyphoses  of  rachitic 
origin  which  arise  during  infancy  show  a  tendency  to  spontaneous 
correction  when  the  supporting  ligaments  and  muscles  become  normal; 
but  when  these  deformities  appear  after  the  third  year,  accompanied 
by  changes  in  the  pelvis,  they  very  often  persist  throughout  life. 

The  Pelvis. — The  most  common  pelvic  deformity  is  shortening  of  the 
anteroposterior  diameter  and  flattening  of  the  pelvis.  A  thickening 
of  the  iliac  crests  also  occurs,  and  many  minor  changes  take  place 
which  give  the  pelvis  an  irregular  or  crumpled  appearance. 

The  Extremities. — Deformities  of  the  extremities  are  usually  sym-^ 
metrical,  and  are  more  marked  in  the  lower  than  in  the  upper  limbs 
because  the  legs  bear  the  weight  of  the  trunk  during  the  stage  in 
which  the  bones  are  abnormally  soft.  The  clavicle  escapes  deformity 
in  all  except  the  most  severe  cases,  but  it  may  be  rendered  quite  prom- 
inent by  either  a  green -stick  fracture  or  an  increase  in  the  convexity 
of  the  inner  third.  The  humerus  is  rarely  deformed  unless  the  infant 
is  allowed  to  crawl  about  too  early,  when  a  forward  and  outward 
curvature  often  develops.  The  epiphyses  are  both  enlarged,  but  not 
as  prominent  as  the  enlarged  epiphyses  of  the  radius  and  ulna,  the 
distal  ends  of  these  two  bones  of  the  forearm  being  very  conspicuous, 
and  producing  that  characteristic  deformity — the  broad  wrist. 

The  shafts  of  the  radius  and  ulna  may  also  be  curved  outward  in 
children  who  use  the  arms  as  well  as  the  legs  for  locomotion,  and 
among  such  children  green-stick  fractures  of  these  bones  are  not 
uncommon.  Sometimes  the  radius  and  ulna  become  twisted  upon 
their  longitudinal  axes,  the  radius  developing  a  spiral  bend  which 
causes  pronation  of  the  hands.  There  are  no  characteristic  deformities 
of  the  hands;  but,  in  rare  cases,  there  are  rachitic  enlargements  of 
the  ends  of  the  metacarpal  bones  and  phalanges  which  resemble 
syphilitic  dactylitis. 

The  lower  extremities  are  usually  deformed,  even  in  light  cases. 
The  femur  is  bent  outward  and  forward  by  the  weight  of  the  child  in 
the  sitting  posture,  for  these  infants  rarely  attempt  to  walk  or  stand 


DIAGNOSIS  237 

because  of  pain.  Coxa  vara  may  also  be  produced  by  the  weight  of 
the  trunk.  The  tibia  and  fibula  usually  curve  outward  and  anteriorly, 
which  produces  bow-legs,  but  may  in  some  cases  curve  inward,  so  that 
knock-knees  result.  These  are  the  most  common  deformities  of  the 
lower  extremities. 

Knock-knees  are  most  frequently  seen  in  girls,  and  they  are  believed 
to  be  caused  by  an  enlargement  of  the  inner  condyles  of  the  femurs. 
Bow-legs,  in  light  cases,  are  due  to  epiphyseal  enlargement,  and  may 
totally  disappear  when  ossification  takes  place  and  the  enlarged 
epiphyses  shrink  and  become  smaller.  In  severe  cases,  bow-legs  are 
the  result  of  an  outward  curvature  which  is  usually  associated  with 
a  more  marked  anterior  curvature,  so  that  the  bones  are  bent  forward 
and  outward. 

Enlargement  of  the  lower  epiphysis  of  the  tibia  is  quite  common, 
and  results  in  the  abnormally  large  ankle  so  often  seen  in  rachitic 
children;  but  marked  enlargement  of  the  upper  epiphyses  of  the 
tibia  and  fibula  is  quite  rare  and  found  only  in  severe  cases  of  rickets. 
In  rachitic  children  fractures  of  the  long  bones  are  usually  of  the 
green-stick  variety,  and  may  be  caused  by  trivial  injuries. 

Permanent  deformity  often  results  from  subperiosteal  fractures. 
The  bones  of  the  feet  are  rarely  aft'ected,  and  rachitic  flat-foot  is  quite 
uncommon.  The  short  stature  of  rachitic  children  is  due  to  arrested 
growth  of  the  long  bones,  and  is  usually  exaggerated  by  the  fact  that 
the  child  is  bow-legged. 

The  Ligaments. — The  ligaments  of  the  rachitic  child  are  relaxed 
and  weakened,  thus  giving  but  little  support  to  the  joints;  this  in 
large  measure  accounts  for  spinal  curvatures  and  other  deformities, 
such  as  knock-knees,  overextension  of  the  knee-joint,  occasionally 
flat-foot,  and  abnormal  laxity  of  all  the  joints  of  the  body. 

The  Muscles. — In  rachitis  the  muscles  are  affected  in  du'ect  pro- 
portion to  the  damage  done  the  bones.  They  are  hypertonic,  undevel- 
oped, and  exceedingly  flabby.  Muscular  weakness  may  be  so  extreme 
as  to  make  us  suspect  paralysis.  These  children  are  very  late  in  sitting 
upright,  standing  and  walking,  because  of  this  lack  of  muscular  tone, 
and  the  weakened  abdominal  musculature  is  largely  responsible  for 
the  protuberant  abdomen  of  the  rachitic  child. 

Diagnosis. — In  well-developed  cases  the  diagnosis  of  rickets  is 
quite  easy.  Even  in  its  milder  form,  and  early  in  the  course  of  the 
disease,  such  symptoms  as  excessive  sweating  of  'the  head  and  neck, 
constipation,  restlessness  at  night,  enlarged  fontanelles,  craniotabes, 
and  delayed  dentition,  are  sufficient  to  warrant  a  diagnosis  of  rickets. 
It  is  this  symptom-complex,  however,  upon  which  the  diagnosis  must 
be  made,  since  most  of  these  symptoms,  appearing  alone,  might  be 
caused  by  other  diseases.  For  example,  craniotabes  occurs  in  syphilis; 
but  the  other  bony  changes  in  syphilis  are  found  in  the  shafts  of  the 
bones,  which  may  even  be  necrotic,  while  in  rickets  the  epiphyses 
show  the  most  marked  changes,  and  necrosis  never  takes  place.  For 
this  reason  the  .r-rays  may  be  of  great  value  in  the  differential  diag- 


238  RICKETS 

nosis  between  syphilis  and  rickets,  and  in  doubtfnl  cases  a  Wassermann 
test  should  also  be  made. 

The  rachitic  rosary,  bowed  legs,  and  epiphyseal  enlargements  are 
the  pathognomonic  signs  in  well-established  cases  which  make  a 
rachitic  child  conspicuous;  but,  occasionally,  cretinism  and  achondro- 
plasia are  mistaken  for  rickets,  or  vice  versa.  Cretinism  can  be 
differentiated  by  the  marked  mental  deficiency,  facial  expression, 
macroglossia,  and  the  striking  disproportion  between  the  height  and 
the  age  of  the  cretin.  Achondroplasia  is  also  distinguished  by  the 
disproportion  between  the  length  of  the  trunk  and  of  the  extremities, 
which  is  much  greater  than  in  rickets,  also  by  the  greater  softness  of 
the  bones,  which  causes,  as  a  rule,  more  striking  deformities. 

The  large  head  of  the  rachitic  child  may  suggest  hydrocephalus; 
but  it  is  cuboid  in  shape,  while  the  hydrocephalic  head  is  globular. 
Other  symptoms  and  signs  of  hydrocephalus,  such  as  softening  of 
the  cranial  bones,  separating  of  the  fontanelles,  and  irritability  of  the 
nervous  system,  also  appear  in  rickets;  but  the  changes  in,  and 
deformities  of,  the  long  bones  so  typical  of  rickets  are  never  seen 
in  hydrocephalus,  and  the  rachitic  head  does  not  undergo  the 
rapidly  progressive  distention  observed  in  the  hydrocephalic  child. 

Scurvy  may  be  differentiated  from  rickets  by  the  acuteness  of  the 
symptoms  and  such  characteristic  signs  as  spongy  gums,  ecchymoses 
of  the  skin,  and  the  tendency  to  hemorrhage  from  the  mucous  mem- 
branes. The  extremities  in  rickets  are  not  nearly  as  tender  as  in 
scurvy,  and  there  is  practically  no  pain.  Rachitic  scoliosis  may 
resemble  caries  of  the  spine;  but,  besides  the  fact  that  other  signs  of 
rickets  are  also  to  be  found,  the  spine  is  flexible  in  early  rickets,  and 
the  curvature  may  be  made  to  disappear  fas  stated  in  the  discussion 
of  the  symptoms)  by  suspending  the  child  by  its  feet  or  laying  it  do^Mi 
upon  its  belly  with  the  legs  extended,  while  in  caries  of  the  vertebra? 
the  curvature  of  the  spme  is  fixed. 

Rachitic  coxa  vara  may  be  differentiated  from  congenital  dis- 
location of  the  hip  by  .r-ray  examination.  Rachitic  pseudoparalysis 
which  results  from  weakness  of  the  muscles  and  ligaments,  may  be 
mistaken  for  cerebral  palsy  or  infantile  paralysis;  but  in  neither  of 
these  organic  nervous  diseases  are  there  any  bony  deformities  such  as 
accompany  rickets.  In  cerebral  paralysis  the  reflexes  are  exaggerated 
and  the  muscles  rigid;  in  infantile  paralysis  the  reflexes  are  absent 
and  the  muscles  flaccid;  while  in  rickets  the  reflexes  are  normal,  and 
the  muscles  simply  exliibit  a  general  weakness  due  to  malnutrition 
and  disuse. 

The  paralyses  caused  by  acute  affections  of  the  brain  and  spinal 
cord,  such  as  polioencephalitis  and  myelitis,  are  characterized  by  a 
sudden  onset,  and  the  paralysis  is  usually  confined  to  certain  groups 
of  muscles  which  show  electrical  changes;  whereas  in  rickets  all  the 
muscles  of  the  body  are  weakened,  but  there  are  no  symptoms  of 
paralysis  nor  of  electrical  changes.  Postdiphtheritic  paralysis  may  be 
differentiated  by  the  absence  of  knee-jerks,  the  various  reflexes  of  the 
body  being  unaffected  in  rickets. 


PROPHYLAXIS  239 

Course  and  Prognosis. — In  this  affection  the  prognosis  is  very  favor- 
able as  regards  hfe,  for  rickets  is  never  fatal  when  uncomplicated,  and 
even  neglected  cases  exhibit  a  tendency  to  spontaneous  recovery 
eventually,  although  great  deformity  may  remain.  If  rickets  is  recog- 
nized early,  and  properly  treated,  perfect  recovery  without  deformity 
is  the  usual  outcome.  The  prognosis  as  to  deformity  depends,  how- 
ever, not  only  upon  treatment,  but  also  to  a  certain  extent  upon  the 
severity  of  the  disease  in  each  particular  case. 

While  the  rachitic  child  is  in  no  danger  of  dying  from  rickets,  yet 
it  is  predisposed  to  intercurrent  acute  infections  because  of  its  lowered 
power  of  resistance,  and  these  diseases  may  cause  death  because  of 
the  child's  want  of  vitality.  Diseases  of  the  respiratory  tract,  in 
particular,  are  usually  serious  in  rachitic  children  on  account  of  the 
abnormal  shape  of  the  thorax,  while  disturbances  of  the  gastro-intes- 
tinal  tract  are  stubborn,  owing  to  the  poor  state  of  the  alimentary 
mucosa. 

The  acute  symptoms  of  rickets  last,  as  a  rule,  for  nine  to  twelve 
months,  recovery  being  gradual.  Improvement  is  shown  by  a  return 
of  muscular  power,  a  lessening  of  the  nervous  symptoms,  and  diminu- 
tion of  the  sweating  of  the  head.  Later  the  bony  changes  and  con- 
sequent deformities  become  less  prominent. 

Prophylaxis. — ^The  prophylaxis  of  rickets  consists  in  so  regulating 
the  diet  of  every  pregnant  woman  that  she  is  sure  to  take  sufficient 
nourishment  during  the  period  of  gestation.  Strict  attention  should 
also  be  paid  to  the  hygienic  and  living  conditions  of  the  expectant 
mother.  The  same  care  should  be  given  to  the  diet  and  hygiene  of 
every  nursing  mother;  for  if  a  healthy  mother  who  has  plenty  of  good 
milk  feeds  her  infant  at  regular  intervals  and  gives  it  nothing  but 
breast  milk,  rickets  will  not  develop  during  the  normal  period  of 
lactation . 

Too  frequent  feeding  should  be  avoided;  once  every  two  hours 
is  ample  during  the  first  six  weeks,  after  that  every  two  and  a  half 
hours,  and  later  once  every  three  hours  is  enough.  No  preparation 
of  patent  baby  food  or  condensed  milk  should  be  given  to  supplement 
breast-feeding;  too  much  of  barley-water  is  also  harmful;  but  if  the 
mother's  milk  is  deficient  in  fats  and  proteins,  or  in  quantity,  a  for- 
mula of  cow's,  milk,  properly  prepared,  should  be  given  in  addition 
to  the  breast  milk. 

Sometimes  the  quality  of  the  mother's  milk  is  improved  by  giving 
her  tonics,  such  as  the  elixir  of  glycerophosphates,  or  the  compound 
syrup  of  hypophosphites,  in  dram  doses  after  meals  during  the  latter 
months  of  pregnancy  and  during  lactation. 

An  infant  should  never  be  weaned  until  it  is  at  least  nine  months 
old  if  the  mother  has  any  milk,  and  if  there  are  no  contraindications 
to  nursing.  On  the  other  hand,  no  child  should  be  permitted  to  nurse 
after  the  fourteenth  month,  at  latest.  When  it  becomes  necessary  to 
wean  a  baby  before  it  is  old  enough  to  take  undiluted  cow's  milk,  it 
should  be  placed  upon  a  feeding  mixtm-e  of  diluted  cow's  milk,  modified 


240  -       RICKETS 

according  to  its  age,  weight,  and  digestive  capability.  In  this  way 
it  is  supphed  with  the  proper  amount  of  fats,  proteins,  and  carbo- 
hydrates. 

Unfortunately,  many  mothers  use  proprietary  infant  foods  for 
such  children;  either  because  they  are  more  easily  prepared,  or  may 
seem  to  be  cheaper,  or  because  some  one  has  recommended  such  and 
such  a  food,  or  the  mothers  have  seen  them  advertised.  The  con- 
tinuous use  of  these  patent  foods  or  of  condensed  milk  as  a  regular 
diet  should  be  condemned  and  strictly  prohibited,  which  will  largely 
prevent  gastro-intestinal  disturbances  and  any  likelihood  of  rickets. 
In  addition  to  modified  cow's  milk,  after  the  sixth  month  it  is  a  good 
plan  to  give  artificially  fed  babies  one-half  to  one  ounce  of  beef  juice 
two  or  three  times  a  week,  and  a  dram  or  two  of  orange  juice  daily. 

Next  in  importance  to  diet  in  the  prevention  of  rickets  is  attention 
to  the  hygiene  and  environment  of  babies  and  children.  If  the  sur- 
roundings are  clean  and  sanitary,  if  the  child  is  given  a  daily  bath, 
if  its  bowels  are  opened  daily,  and  if  it  gets  moderate  exercise  and 
plenty  of  fresh  air,  much  is  done  to  lessen  the  susceptibility  to  rickets. 
The  foregoing  prophylactic  treatment  is  most  essential  in  the  children 
of  a  family  in  which  there  is  a  predisposition  to  rickets,  and  should  be 
rigidly  carried  out. 

Treatment. — The  active  treatment  of  rickets  consists  chiefly  in 
regulation  of  the  diet,  the  hygienic  welfare  of  the  rachitic  child  being 
of  secondary  importance.  The  treatment  of  deformities  due  to  rickets 
needs  consideration,  but  this  is  usually  a  problem  for  the  orthopedist. 
In  the  majority  of  cases,  active  rachitic  processes  are  really  in  progress 
only  up  to  the  eighteenth  month;  therefore  it  is  important  that 
rickets  be  recognized  and  treated  before  this  time,  if  deformities  are 
to  be  prevented.  Treatment  instituted  after  the  second  year  has  but 
little  effect,  as  at  this  age  rachitic  changes  have  already  taken  place. 

Dietetic  Treatment. — When  a  breast-fed  baby  becomes  rachitic,  the 
diet  of  the  mother  should  be  increased  both  in  quantity  and  quality 
to  insure  breast  milk  for  the  infant  which  will  contain  an  ample  pro- 
portion of  fat  and  proteins.  If  the  milk  can  not  be  made  richer 
because  the  mother  is  not  well,  either  a  wet  nurse  should  be  secured 
or  the  breast  feedings  supplemented  by  several  bottle  feedings  of  a 
properly  prepared  formula.  The  infant  should  not  be  taken  from 
the  breast,  however,  unless  the  mother's  milk  can  not  be  sufficiently 
improved  to  make  it  agree  with  the  baby,  or  the  mother  again  becomes 
pregnant. 

If  we  find  that  a  rachitic  infant  is  being  nursed  beyond  the  normal 
period  of  lactation,  it  should  be  promptly  weaned,  and  given  food 
suitable  to  its  age  and  digestive  power.  Besides  increasing  the  diet 
of  the  nursing  mother  whose  baby  has  rickets,  her  surroundings  and 
personal  hygiene  should  receive  attention,  she  should  take  moderate 
exercise,  plenty  of  rest,  and  never  allow  herself  to  become  fatigued. 
In  this  manner  her  milk  may  be  so  improved  both  in  quantity  and 
quality  that  she.  can  properly  nourish  the  child. 


THE  AT  MEN  T  241 

Rickets  in  the  artificially  fed  child  should  be  carefully  investigated 
and  the  diet  corrected.  If  patent  foods  or  condensed  milk  mixtures 
are  being  given,  these  should  be  stopped  immediately,  If  a  formula 
of  cow's  milk  is  being  used,  this  should  be  adjusted,  and  the  feedings 
prepared  on  a  percentage  basis  that  will  insure  a  sufficiency  of  fat 
and  proteins  and  no  excess  of  carbohydrates. 

If  there  are  evidences  of  gastric  or  intestinal  indigestion,  such  as 
anorexia,  vomiting,  and  diarrhea,  the  bowels  should  first  be  swept  out 
with  one  to  three  drams  of  castor  oil,  and  a  formula  given,  at  first 
very  weak,  the  strength  of  which  can  be  gradually  increased  as  the 
digestion  improves. 

The  rachitic  infant  usually  comes  under  observation  when  it  is 
between  tw^elve  and  eighteen  months  old,  and  at  this  age  its  diet 
should  be  composed  of  one  quart  of  milk  daily  with  at  least  an  ounce 
of  cream  (or  some  other  substance  rich  in  animal  fat,  such  as  butter), 
also  the  yolk  of  an  egg,  and  bread.  Later,  if  the  digestion  is  good, 
a  few  cereals,  such  as  rice,  cream  of  wheat,  or  barley  may  be  given 
together  with  fresh  vegetables,  such  as  spinach,  peas,  beans,  or 
asparagus,  and  a  small  amount  of  chicken,  fish  or  mutton. 

This  diet  is  very  liberal,  and  not  difficult  to  follow,  the  chief  object 
being  to  give  an  ample  suppl}-  of  fat  and  to  limit  the  carbohydrates. 
Fresh  milk  is,  perhaps,  the  most  valuable  article  of  food  for  the  rachitic 
child,  therefore  it  should  always  be  taken  plentifully  at  frequent 
intervals  throughout  the  day.  Fresh  fruit  juices  and  beef  juice  are 
very  beneficial,  and  the  craving  for  salt  which  these  children  often 
exhibit  is  an  indication  of  their  need  for  it,  which  should  be  satisfied. 

Cod-liver  oil  is  to  be  regarded  as  a  form  of  nourishment  for  rachitic 
children,  and  should  be  given  in  every  case  unless  it  causes  gastro- 
intestinal disturbances,  in  which  circumstance  it  should  not  be  used 
during  extremely  hot  weather.  Children  under  one  year  of  age  may 
be  given  one  or  two  drams,  di^'ided  in  three  doses,  during  the  day; 
older  children  may  take  one  dram  three  times  dail}',  or  even  more 
than  this  if  the  stomach  tolerates  it,  and  it  can  be  assimilated.  Olive 
oil  is,  perhaps,  not  as  valuable  as  cod-liver  oil,  for  these  children  seem 
to  require  animal  fats;  but  it  may  be  given  in  the  same  dosage,  or  even 
in  larger  quantities,  since  it  is  not  so  harmful  to  the  digestion. 

Hygienic  Treatment. — Rachitic  children  should  be  kept  out  of  doors 
as  much  as  possible,  and  the  rooms  in  which  they  sleep  should  get 
plenty  of  sunlight  and  fresh  air.  The  homes  of  these  children  should 
be  clean,  sanitary,  and  aftord  plenty  of  ventilation;  but,  unfor- 
tunately, such  living  conditions  are  hard  to  procure,  since  cases  of 
rickets  usually  develop  in  the  large  cities;  therefore  it  is  wise  to  send 
such  children  to  the  seashore  or  country.  The  seashore  is,  perhaps, 
preferable  because  of  its  stimulating  effect  on  the  appetite  and 
metabolism. 

Care  of  the  skin  should  not  be  overlooked,  and  a  daily  bath  at  the 
temperature  of  the  body  should  be  given.  Inunctions  of  olive  oil 
are  not  advisable  because  they  interfere  with  the  secretory  function 
16 


242  RICKETS 

of  the  skin.  Cold  baths  are  harmful  during  infancy;  but  a  brine 
bath  made  by  adding  one  ounce  of  sea  salt  to  two  gallons  of  water 
is  very  beneficial,  given  each  morning,  and  followed  by  a  brisk  massage 
or  rub.  Exercise  is  absolutely  essential  to  improve  the  muscular 
tonicity,  and  should  be  encouraged  in  so  far  as  it  does  not  increase 
deformities;  for  instance,  no  attempt  at  walking  should  be  permitted 
while  the  bones  are  soft,  as  the  legs  will  become  bowed  by  the  weight 
of  the  trunk. 

Drug  Treatment. — It  is  difficult  to  estimate  the  value  of  drugs  in 
the  treatment  of  rickets  inasmuch  as  there  is  a  tendency  to  recovery 
under  proper  dietetic  and  hygienic  care.  There  are  no  specifics  for 
the  cure  of  the  disease,  hence  tonics  and  preparations  for  special 
symptoms  meet  all  the  indications.  Owing  to  the  nature  of  the 
rachitic  process  in  the  bones,  it  is  advisable  to  give  hypophosphites 
of  lime  and  soda,  in  combination  with  cod-liver  oil,  each  teaspoonful 
of  the  oil  containing  one-half  to  one  grain  each  of  sodium  hypophos- 
phite  and  of  calcium  hypophosphite.  Lime  should  always  be  given, 
preferably  in  the  form  of  the  glycerophosphates  or  the  lactophosphates, 
dose  one  to  five  grains,  three  times  a  day.  The  elixir  of  ghxerophos- 
phates  has  proven  of  value  in  rickets  because  of  its  tonic  effect,  and 
may  be  given  in  10-  to  30-drop  doses. 

There  is  great  diversity  of  opinion  and  much  discussion  as  to  the 
value  of  phosphorus  in  rickets;  but  it  should  always  be  administered, 
since  experiments  have  proven  that  the  giving  of  phosphorus  to  young 
animals  in  suitable  dosage  is  followed  by  an  increased  activity  of  the 
processes  in  the  epiphyseal  ossification  zone.  The  one  possible  objec- 
tion to  it  is  that  it  may  set  up  gastro-intestinal  disturbances;  but,  if 
the  digestion  is  not  already  deranged,  it  may  be  given  in  2T0  to  yi-o 
of  a  grain  doses,  three  times  a  day,  either  in  the  form  of  the  official 
oil,  which  may  be  combined  with  olive  or  cod-liver  oil,  or  as  Thomp- 
son's solution,  which  contains  oV  of  a  grain  of  phosphorus  to  the 
dram. 

It  is  claimed  by  some  clinicians  that  better  results  are  obtained 
when  phosphorus  is  combined  with  cod  liver  oil.  Other  authorities 
maintain  that  the  efi^ect  of  the  phosphorus  is  negligible,  and  that 
the  benefit  derived  from  this  combination  is  due  solely  to  the  cod- 
liver  oil.  Phosphorus  is  certainly  of  little  or  no  value  in  the  later 
stages  of  rickets,  the  most  favorable  time  for  its  administration  being 
early  in  the  disease.  It  is  especially  beneficial  in  the  cases  accompanied 
by  craniotabes. 

Owing  to  the  anemia  present  in  rachitic  children,  iron  is  always 
indicated,  and  may  be  administered  in  several  forms.  The  syrup  of 
ferrous  iodide  is  well  borne  by  most  children  in  5-  to  10-grain  doses 
after  each  meal,  or  the  hypophosphite  of  iron  may  be  given  in  1-  to 
5-grain  doses,  three  times  a  day.  Tincture  of  ferric  chloride  should 
be  administered  only  to  those  children  who  show  no  gastro-intestinal 
disturbance,  and  then  cautiously  in  1-  to  3-drop  doses,  but  the  sac- 
charated  carbonate  of  iron  is  very'  easily  borne  by  the  stomach,  and 
mav  be  taken  in  1-  to  3-grain  doses. 


TREATMENT  OF  COMPLICATIONS  243 

Fowler's  solution,  1  to  3  drops,  is  occasionally  administered  for  its 
tonic  effect,  and  the  dose  may  be  gradually  increased.  Glandular 
extracts  have  been  employed  with  good  results  in  some  cases,  but 
their  use  in  rickets  is  not  universal.  Thyroid  extract,  in  ^-grain  doses, 
may  be  given  twice  or  three  times  daily  with  one  of  the  iron  prepara- 
tions, preferably  the  saccharated  carbonate.  The  pituitary  gland  has 
also  been  used. 

Of  the  drugs  indicated  for  special  symptoms,  atropine  sulphate  in 
g-^o  of  a  grain  dose,  three  times  a  day,  may  be  recommended  for  the 
relief  of  the  profuse  sweating  of  the  head.  The  bowels  may  be  kept 
regular  by  the  administration  of  aromatic  fluidextract  of  cascara 
sagrada  in  15-  to  30-drop  doses  when  necessary,  or  milk  of  magnesia 
in  |-  to  2-dram  doses  as  required.  If  the  digestion  is  poor,  an  effort 
should  be  made  to  improve  it  by  giving  tincture  of  nux  ^'omica  in 
1-  to  3-drop  doses  combined  wath  dilute  hydrochloric  acid,  drops  1 
to  3,  before  meals,  or  by  giving  quinine  sulphate  in  \-  to  f-grain  doses 
three  times  a  day. 

It  is  also  a  good  plan  to  give  these  children  occasionally  |  to  1  grain 
of  hydrargyrum  cum  creta,  and  thoroughly  to  cleanse  the  bowels  once 
or  twice  a  month  with  a  ^w^ative  dose  of  castor  oil  (1  dram  to  | 
ounce).  If  there  is  a  tend^B^to  convulsions,  sodium  bromide  should 
be  given  in  2-  to  5-grain  (Ws^,  three  times  a  day. 

Treatment  of  Complications. — Bronchitis  and  bronchopneumonia 
are  the  two  most  common  complications  referable  to  the  respiratory 
tract,  and  call  for  the  usual  treatment;  but  antirachitic  remedies  are 
more  effective  than  any  special  measures  wdiich  can  be  employed. 
Disturbances  of  the  alimentary  tract  are  by  far  the  most  frequent 
complications,  and  must  be  treated  in  the  usual  way.  In  acute  attacks 
with  diarrhea,  an  initial  dose  of  castor  oil,  1  to  2  di*ams,  should  be 
given,  followed  after  ten  hours  by  bismuth  subnitrate  in  10-  to  20-grain 
doses,  three  or  four  times  daily.  The  diet  should  be  considerably 
restricted  for  several  days.  But  the  treatment  of  the  constitutional 
disease  is  of  the  utmost  importance,  and  should  always  be  carried 
out. 

Convulsions  form  the  most  common  nervous  manifestation  of 
rickets.  Immediate  treatment  consists  in  placing  the  child  in  a  tub 
of  water  at  100°  to  106°  F.  for  three  or  four  minutes,  after  which  it 
should  be  dried  quickly  and  put  into  bed.  Another  effective  measure 
is  to  wTap  the  child  for  five  to  ten  minutes  in  a  blanket  wTung  out 
of  hot  water,  and  then  wTap  it  up  in  a  hot  dry  blanket.  If  these 
measures  do  not  stop  the  convulsions,  from  5  to  15  grains  of  potas- 
sium bromide  with  2  to  5  grains  of  chloral  hydrate  may  be  injected 
into  the  rectum.  Morphine  sulphate,  grain  -^  to  -gV,  may  be  given 
hypodermically  in  severe  cases,  or  inhalations  of  chloroform  may  be 
tried.  An  enema  of  warm  salt  solution  or  soapsuds  should  always  be 
given,  and  may  in  itself  afford  relief. 

Laryngismus  stridulus,  a  less  frequent  complication  of  rickets,  is 
due  to  a  neurotic  spasm  of  the  vocal  cords.     It  should  be  treated 


241  RICKETS 

by  the  use  of  a  hot  pack  and  an  enema,  or  1  to  2  drams  of  castor  oil. 
If  there  is  a  tendency  to  nocturnal  attacks,  potassium  bromide,  5 
to  15  grains,  and  chloral  hydrate,  2  to  4  grains,  should  be  given  each 
evening. 

In  tetany,  a  rare  complication  of  rickets,  there  is  a  painful  spasm 
of  the  muscles  of  the  hands  and  feet.  It  requires  but  little  special 
treatment,  although  it  is  advisable  to  use  a  belly  band,  and  to  wrap 
the  arms  and  legs  in  cotton-wool  during  an  attack.  The  nervous 
manifestations  of  rickets,  in  common  with  complications  in  various 
parts  of  the  body,  call  for  the  recognition  of  the  primary  disease 
and  its  efficient  treatment  before  a  permanent  cure  can  be  expected. 

Treatment  of  Deformities. — The  prevention  of  deformities  is  a  very 
essential  part  of  the  management  of  a  case  of  rickets,  and  consists 
in  limiting  motion  during  that  period  of  the  disease  when  the  bones 
are  soft.  The  child  who  shows  a  tendency'  to  curvature  of  the  spine 
should  be  kept  in  the  recumbent  posture  and  not  allowed  to  sit  up 
unsupported. 

If  kyphosis  appears,  it  should  be  treated  by  placing  the  child  on  a 
Bradford  frame  or  a  hard  bed,  and  keeping  it  in  the  recumbent  posture. 
In  severe  cases  it  is  advisable  to  correct  the  deformity  each  day  by 
turning  the  child  upon  its  abdomen,  and  raising  the  buttocks  while 
pressure  is  made  upon  the  spine.  Plaster  casts  should  only  be  used 
in  selected  and  severe  cases,  for  they  interfere  with  respiration,  and 
increase  the  tendency  to  bronchitis  and  bronchopneumonia.  When 
there  is  pelvic  deformity,  the  sitting  posture  must  be  avoided,  espe- 
cially in  girls.  Bow-legs  and  knock-knees  can  be  largely  prevented  by 
keeping  children  off  their  feet  until  the  bones  harden  and  the  rachitic 
changes  have  passed  away.  Creeping  also  should  be  prohibited  while 
the  bones  of  the  arms  are  soft.  If  bowing  occurs,  properly  fitting 
braces  should  be  worn  continuously,  and  walking  discouraged.  If  the 
child  curls  up  its  legs  in  bed,  external  splints  should  be  applied. 

Intelligent  manipulation  of  the  deformed  extremities,  if  done 
early,  may  reduce  the  curvatures  somewhat;  but,  after  the  third  year, 
correction  of  deformities  by  braces  or  manipulation  is  impossible. 
Massage  is  useful  in  strengthening  the  weakened  muscles,  and  may 
to  a  certain  extent  inhibit  the  progress  of  deformity;  but  it  should 
be  performed  carefully  and  judiciously. 

Osteotomy  for  the  correction  of  deformities  should  be  postponed 
until  after  the  seventh  or  eighth  year,  because  many  rachitic  curva- 
tures lessen  considerably  by  this  time,  and  also  because  there  is 
danger  that  more  or  less  curvature  may  follow  such  an  operation  if 
it  be  done  too  early. 

In  very  young  infants  curvatures  of  the  extremities  have  been 
absolutely  corrected  by  the  use  of  a  plaster-of-Paris  cast.  The  fore- 
going treatment  of  deformities  from  rickets  is  largely  a  problem  for 
the  orthopedist,  and  it  is  always  advisable  to  consult  one  in  order  to 
secure  the  best  results. 


ACUTE   RICKETS  245 

CONGENITAL   RICKETS. 

This  form  of  rickets  is  seldom  encountered  in  the  United  States, 
but  a  few  scattered  cases  have  been  reported.  It  arises  during  intra- 
uterine Hfe  when  the  fetus  is  deriving  its  sustenance  through  the 
placental  circulation,  and  is  due  to  malnutrition  and  chronic  disease 
in  the  pregnant  mother.  These  infants  exhibit  at  birth  the  character- 
istic rachitic  changes  and  deformities,  the  histological  changes  in  the 
bony  tissue  being  to  a  certain  extent  the  same  as  in  older  children. 
The  congenital  form  of  rickets  is  rarely  severe,  but  the  rachitic  rosary, 
epiphyseal  enlargements,  and  craniotabes  may  be  apparent  in  these 
children  at  birth. 

ADOLESCENT,    OR   LATE,    RICKETS. 

This  form,  also,  is  rare  in  America,  but  not  extremely  uncommon 
in  Europe.  It  is  said  tO'  occur  more  often  in  girls  than  in  boys,  and 
may  appear  at  any  time  between  the  sixth  year  and  puberty,  or  even 
later.  In  these  cases  there  are  both  beadmg  of  the  ribs  and  epiphyseal 
enlargement,  but  the  skull  is  normal,  since  ossification  of  the  cranial 
bones  is  complete  before  the  onset  of  the  disease.  Among  the 
deformities  caused  by  late  rickets  may  be  mentioned  bow-legs,  knock- 
loiees,  flat-foot,  femoral  curves,  coxa  vara,  and  scoliosis. 

ACUTE    RICKETS. 

Although  cases  of  acute  rickets  have  been  described,  rachitic  changes 
are  essentially  chronic,  and  the  existence  of  an  acute  form  of  this 
disease  is  extremely  doubtful.  Most  cases  of  so-called  "acute 
rickets,"  if  investigated  thoroughly,  will  prove  to  be  scurvy  or  some 
other  disease  of  similar  nature. 


CHAPTER   XIII. 
DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT. 

In  the  consideration  of  the  diseases  of  children,  affections  of  the 
gastro-intestinal  tract  are  undoubtedly  the  most  important,  for  they 
form  the  basis  of  many  of  the  illnesses  of  infancy,  and  constitute  a 
large  proportion  of  the  disorders  which  occur  between  infancy  and 
puberty.  Several  factors  may  explain  the  preponderance  of  gastro- 
intestinal disturbances  over  those  of  other  systems  of  the  body  which 
are  called  upon  to  functionate  after  birth. 

One  of  the  most  significant  reasons  why  the  digestive  tract  so  often 
breaks  down  under  the  strain  is  that,  of  all  the  systems  of -the  body, 
this  alone  must  utilize  material  foreign  to  the  body.  The  circulatory 
system  is  furnished  with  a  full  quota  of  blood  at  birth;  from  birth 
onward  the  air  utilized  by  the  respiratory  system  varies  only  slightly 
in  composition;  but  even  in  the  breast-fed  infant,  and  vastly  more  so 
in  the  one  artificially  fed,  the  digestive  system  must  use  material  which 
constantly  varies  in  strength  and  amount. 

Under  proper  conditions,  the  digestive  apparatus  after  birth  is 
capable  of  digesting  and  assimilating  the  normal  food  with  reasonable 
variations  for  the  individual  at  every  period  of  life;  therefore  the  true 
explanation  of  gastro-intestinal  affections  encountered  in  infancy  and 
childhood  lies,  not  in  the  inability  of  the  child  to  assimilate  its  food, 
but  in  the  failure  of  the  parents  to  appreciate  certain  peculiarities, 
both  in  structure  and  function,  of  the  digestive  system  of  the  infant 
or  child,  as  compared  with  the  adult,  which  in  most  instances  leads  to 
overtaxation  of  the  gastro-intestinal  tract  by  the  introduction  of 
food  unsuitable  as  to  quantity  or  quality. 


DISEASES  OF  THE   LIPS. 


HERPES. 


Herpes  labialis  is  quite  a  common  affection  in  children,  and  receives 
its  synonym  "fever  blister"  because  it  is  frequently  associated  with 
a  rise  in  temperature.  It  is  often  seen  in  pneumonia,  but  rarely  occurs 
in  typhoid  fever,  and  the  appearance  of  herpes  in  a  febrile  case  where 
typhoid  is  suspected  is  of  no  little  significance  in  discriminating  against 
that  disease.    The  blisters  are  of  little  importance  except  for  the  fact 


PERLECHE 


24' 


tint   after  the  eriist  forms,  healing  i^  sometimes  greatly  retarded  by 
the  iiabit  of  pieking  the  sores  whicli  ehildren  will  persist  m,  unless 
prevented  in  some  way  from  reaching  them.     If  this  can  be  done 
and  they  are  dusted  with  either  boric  acid  or  zmc  oxide,  they  will 
disappear  in  the  course  of  a  few  days. 

PERLECHE. 

Perleche  is  a  cracking  and  ulceration  of  the  mucous  membrane  of 
the  lips  usually  occurring  at  the  angles  of  the  mouth,  and  affecting 
the  vermilion  border  of  the  mucous  membrane.  It  is  infectious  m 
nature,  but  not  syphilitic.  .      ,  .,  ,  , 

Etiology.— Perleche  is  usually  observed  in  children  who  are  m  poor 
physical  condition,  and  present  other  signs  of  malnutrition,  such  as 
anemia,  chronic  nasopharyngitis,  adenitis,  or  scrofula.  It  is  occa- 
sionally observed  before  the  second  year,  but  is  most  common  alter 
the  period  of  infancv.  The  infection  is  usually  conveyed  through 
some  tinv-  fissure  in  the  lip,  and  manifests  itself  by  swelling  and 
hvperemia,  accompanied  by  smarting  and  itching  which  cause  the 
child  constantlv  to  lick  the  corners  of  the  mouth.  The  tmy  hssure 
which  was  the  port  of  entry  of  the  infection  becomes  larger,  and  other 
cracks  and  fissures  appear  as  a  result  of  the  constant  irritation  pro- 
duced bv  the  tongue.  A  grayish-white  ulcer  forms  at  the  angle  ot 
the  mouth;  this  is  composed  of  macerated,  thickened,  and  opaque 
mucous  membrane  which  closely  simulates  a  syphilitic  mucous  patch. 
The  condition,  if  not  relieved,  may  persist  for  several  weeks,  and  m 
some  instances  constitutes  a  grave  menace  to  the  health  of  an  already 
anemic  child,  for  movements  of  the  lips  may  be  so  painful  as  to  make 
the  little  one  refuse  its  food.  The  erosions  are  linear  m  shape,  and 
involve  both  corners,  where  the  rhagades  may  be  seen  slightly  elevated 
with  a  reddened  base. 

Diagnosis.— The  diagnosis  of  peileche  cannot  be  clearly  made 
without  considering  syphilitic  rhagade,  eczema  of  the  lips,  and  herpes 
labialis.  Absence  of  induration  at  the  base,  and  of  mucous  patches 
inside  the  mouth,  strongly  indicates  perleche.  Eczema  of  the  lips 
is  usually  associated  with  lesions  in  other  parts  of  the  body,  and 
responds  much  more  readily  to  treatment  than  perleche.  The  severity 
of  the  infection  in  perleche,  and  the  pain  and  smarting  present,  will 
generallv  exclude  herpes. 

Treatment.— The  usual  duration  of  perleche  is  from  two  to  three 
weeks,  but  it  should  always  be  treated  since  it  may  become  chronic 
if  neglected.  The  best  application  is  silver  nitrate,  10  per  cent,  solu- 
tion, followed  daily  by  a  dusting  powder  of  zinc  oxide,  or  the  applica- 
tion of  boric  acid  ointment  to  the  raw  surface  of  the  lips.  Excellent 
results  are  obtained  by  the  use  of  an  ointment  of  the  red  oxide  ot 
mercury.  ^  •  i 

Another  mode  of  treatment  which  has  often  proven  benehciai, 
although  not  as  quickly  effective  as  those  above  outlined,  is  to  bathe 


248  DISEASES  OF  THE  G ASTRO-INTESTINAL  TRACT 

the  corners  of  the  mouth  in  a  1  to  2000  bichloride  solution,  fol- 
lowing this  immediately  and  every  three  hours  thereafter  by  the 
application  of  ichthyol,  25  per  cent. 


DISEASES   OF   THE   TONGUE. 

GEOGRAPHICAL    TONGUE. 

Epithelial  desciuamation  of  the  dorsum  of  the  tongue  is  a  common 
affection  in  children,  and  is  caused  by  a  chronic  superficial  desquamat- 
ing glossitis  which  denudes  the  tongue  of  areas  of  epithelium  and 
gives  it  a  so-called  "geographical"  aspect,  because  of  the  irregular, 
round,  and  crescent-shaped  patches  it  presents.  These  areas  are 
very  variable  in  size,  and  may  coalesce  or  diminish  until  they  disap- 
pear, or  suddenly  grow  again  with  great  rapidity.  The  denuded 
patches  are  red  and  smooth,  the  papillae  being  absent,  the  margins 
are  grayish  or  whitish,  but  the  remainder  of  the  surface  of  the  tongue 
is  normal. 

The  cause  of  geographical  tongue  is  unknown.  It  is  observed  in 
rich  and  poor  children  alike,  and  is  apparentlv  uninfluenced  by  hygienic 
care  of  the  mouth.  Once  observed  in  a  child  it  will  be  found  to  recur 
at  varying  intervals  until  adolescence,  when  it  tends  to  disappear. 
In  itself,  the  condition  is  of  no  significance,  except  that  it  is  often 
mistaken  as  a  symptom  of  some  other  disease.  No  form  of  treatment 
has  as  yet  proven  effective,  so  that  spontaneous  cure  is  the  ultimate 
outcome.  ]Most  of  the  cases  which  have  come  under  my  observation 
occurred  in  rather  weak  and  debilitated  children,  but  improvement 
in  theu'  general  physical  health  failed  to  influence  the  local  condition. 

GLOSSITIS. 

This  affection  is  very  rare  during  childhood,  but  is  occasionally 
seen  as  a  result  of  accidental  trauma  from  biting  the  tongue  in  a  fall, 
rage,  or  convulsion.  Now  and  then  glossitis  is  caused  by  a  strong 
alkali  or  acid  taken  by  mistake,  or  by  the  sting  of  an  insect  or  a  burn. 
Infection  and  inflammation  of  the  tongue  are  always  followed  by 
enlargement  of  the  organ,  and  much  pain.  If  the  infection  be  severe, 
the  tongue  may  become  so  large  as  to  protrude  from  the  mouth 
and  also  interfere  with  respiration  and  deglutition.  Recovery  usually 
takes  place  within  a  few  days;  but  mechanical  obstruction  from 
enlargement  of  the  organ  often  greatly  alarms  the  parents,  and  may 
require  urgent  measures  for  relief. 

Treatment. — The  child's  nourishment  should  be  kept  up;  and,  if 
swallowing  is  extremely  painful,  liquids  should  be  introduced  by 
means  of  a  catheter  through  the  nose.    "When  the  symptoms  are  most 


ALVEOLAR  ABSCESS  249 

acute,  ice  a]jplied  to  the  under  surface  of  the  lower  jaw,  and  kept  in 
the  mouth  continually,  will  help  to  relieve  the  pain.  If  the  swelling 
becomes  extreme  multiple  punctures  may  be  made,  or  the  dorsum  of 
the  tongue  may  be  scarified  on  either  side  of  the  raphse. 

MICROGLOSSIA. 

Microglossia  is  a  very  rare  condition  in  which,  owing  to  an  arrest 
in  development,  the  tongue  is  much  smaller  than  normal.  The  cause 
of  microglossia  is  unknown,  and  since  the  diminutive  tongue  causes 
little  or  no  disturbance  in  talking  or  feeding,  the  condition  is  of  little 
importance  except  as  a  contrast  with  the  opposite  condition,  macro- 
glossia,  which,  though  rare,  occurs  with  greater  frequency. 

MACROGLOSSIA. 

Enlargement  of  the  tongue  may  be  due  to  an  overgro^^i;h  of  the 
lymphogenous  structure  (lymphangioma  or  cavernous  macroglossia), 
to  an  increase  in  the  muscular  and  connective  tissue  elements  (fibrinous 
macroglossia),  and  in  some  instances  to  an  excess  of  both  lymphogenous 
and  connective  tissue  elements.  Occasionally  an  abnormally  long 
tongue  is  rendered  very  mobile  by  an  unusually  lax  frenum,  w^hich 
makes  it  possible  for  the  child  to  swallow  its  tongue;  several  cases 
of  this  kind  are  recorded  in  literature.  Aside  from  this  accident,  the 
tongue  may  become  so  large  as  to  fill  up  the  entire  mouth,  and  prevent 
nursing  or  the  taking  of  food,  or  may  even  protrude  from  the  mouth, 
which  causes  it  to  become  bruised  and  chapped,  and  the  inflammation 
results  in  further  enlargement. 

True  macroglossia,  which  is  a  congenital  condition,  should  never 
be  confused  wdth  the  enlarged  tongue  of  the  cretin,  familiar  to  all, 
in  whom  the  tongue  is  of  a  deep  bluish  color,  and  shows  marks  of 
the  teeth,  is  prolapsed,  and  slightly  protrudes  from  the  mouth. 

Treatment. — An  excessive  degree  of  true  hypertrophy  of  the  tongue, 
resulting  in  interference  with  the  taking  of  food,  calls  for  the  surgical 
removal  of  a  wedge-shaped  piece  of  the  organ  to  prevent  death  from 
starvation.  The  cretin's  tongue,  no  matter  how  large,  can  always 
be  reduced  by  the  proper  administration  of  thyroid  gland,  and  the 
tongue  with  a  mild  degree  of  macroglossia  is  usually  accommodated 
by  the  natural  increase  in  size  of  the  oral  cavity. 


DISEASES   OF   THE   MOUTH. 

ALVEOLAR   ABSCESS.     . 

Many  children  are  allowed  to  reach  the  age  of  eight  or  ten  years 
before  the  practice  of  brushing  the  teeth  is  insisted  upon,  and,  as  a 


250  DISEASES  OF   THE  GASTRO-INfESflNAL   TRACT 

result,  caries  of  the  teeth  is  very  comuion  (hiring  childhood.  Caries 
is  followed  by  infection  and  inflammation,  perhaps  by  an  abscess  at 
the  root  of  the  tooth  which  causes  great  pain  and  swelling  of  the 
face  and  jaw.  The  breath  becomes  foul.  In  addition  to  local  signs 
and  symptoms,  there  are  often  disturbances  of  digestion  and  slight 
fever  from  inability  to  masticate  the  food  properly. 

Treatment. — Relief  of  pain  is  usually  the  immediate  indication, 
and  this  may  be  met  by  the  application  of  hot  poultices  externally 
over  the  aflfected  jaw,  and  by  painting  the  gums  hourly  with  equal 
parts  of  tincture  of  iodin  and  tincture  of  opium.  If  fluctuation  can 
be  detected  the  gums  should  be  incised,  as,  if  allowed  to  remain 
unopened,  the  abscess  usually  breaks,  and  the  pus  .is  evacuated  into 
the  mouth.  In  some  instances  these  abscesses  have  been  known  to 
rupture  into  the  nose,  antrum,  or  maxillary  sinus. 

Upon  the  detection  of  inflammation  at  the  root,  the  best  treatment 
by  far  is  immediate  extraction  of  the  tooth,  which  relieves  the  con- 
dition at  once.  Following  the  evacuation  of  the  pus,  an  antiseptic 
mouth  wash  should  be  employed  for  several  days,  for  which  pur- 
pose 20  per  cent,  hydrogen  peroxide  or  25  per  cent,  liquor  alkalinus 
antisepticus  will  prove  very  efficacious. 

ULCER    OF    THE   FRENUM. 

Ulceration  of  the  frenum  of  the  tongue  is  usually  observed  in  weak 
infants,  or  as  the  result  of  whooping-cough.  The  ulcer  is  caused  by 
the  contact  of  the  central  incisors  with  the  frenum  during  the  act  of 
coughing,  this  producing  a  shallow,  clean-cut,  sharp-edged  ulcer  on 
either  side  of  the  frenum.  It  is  most  frequently  seen  in  children 
between  one  and  two  years  of  age,  and  occurs  in  younger  children 
only  after  they  have  cut  their  central  incisors. 

Treatment.^ — The  ulcers  generally  tend  to  heal  spontaneously  in 
the  course  of  a  week  or  ten  days;  but  healing  is  considerably  more 
rapid  if  a  2  per  cent,  solution  of  silver  nitrate  is  applied  daily  to  the 
ulcerated  areas. 

BEDNAR'S    APHTHA. 

Bednar's  aphthse  is  a  symmetrical  ulceration  which  occurs  on  each 
side  of  the  palatine  ridge  over  the  hamular  process  of  the  palate  bone, 
usually  in  very  young  infants,  and  most  commonly  between  the 
second  and  third  months.  It  is  practically  alw^ays  due  to  traumatism 
from  too  vigorous  cleansing  of  the  mouth,  which  produces  abrasions 
of  the  mucous  membrane.  At  this  particular  point  these  abrasions 
quickly  become  ulcers  because  of  the  poor  local  circulation  and  the 
tense  condition  of  the  mucous  membrane.  Bednar's  aphthse  has  been 
known  to  follow  thrush,  and  may  also  be  caused  by  the  use  of  an 
improperly  shaped  nipple,  but  is  never  due  to  syphilis. 

Symptoms. — The  lesions  are  oval  and  shallow,  usually  bean-shaped, 
and  are  covered  with  a  grayish  necrotic  membrane  which  is  very 


CATARRHAL  STOMATITIS  251 

adlicreiit,  and,  if  removed,  reveals  a  siiiootli,  reddened  base.  Xursiiig 
is  so  painful  that  the  infant  may  take  the  l)reast  for  only  a  few  minutes 
at  a  time  or  refuse  to  nurse  at  all. 

Treatment. — These  ulcers  should  be  prevented  by  cleansing  the 
mouth  with  the  greatest  care  in  order  to  avoid  bruising  the  mucous 
membrane,  and  if  a  badly  shaped  artificial  nipple  is  used  it  should 
be  changed  and  a  proper  one  substituted.  The  ulcers  should  be 
touched  daily  with  a  10  per  cent,  silver  nitrate  solution,  and  the  mouth 
must  be  kept  clean  by  following  each  feeding  with  a  tablespoonful 
of  water.  In  an  ordinary  case  of  Bednar's  aphthae  the  ulcers  usually 
heal  up  in  the  course  of  a  few  days. 

CATARRHAL    STOMATITIS. 

Catarrhal  stomatitis  is  an  extensive  inflammation  of  the  mucous 
membrane  of  the  mouth,  occurring  usually  dining  the  first  two  years 
of  life.  As  a  rule,  it  is  due  to  local  irritation  from  too  vigorous  cleans- 
ing of  the  mouth,  but  it  is  also  seen  in  association  with  thrush, 
occasionally  during  dentition,  and  in  acute  contagious  diseases. 

Symptoms. — The  inflammation  is  at  first  usually  localized  in  some 
particular  area  of  the  oral  mucous  membrane,  but  shows  a  tendency 
to  spread  and  involve  the  whole  mouth.  The  inflamed  area  is  intensely 
engorged,  reddened,  and  sharply  demarcated  from  the  surrounding 
mucous  membrane.  As  the  disease  increases  in  severity  the  gums 
become  swollen,  the  tongue  is  coated,  and,  although  there  is  an 
increased  secretion  of  saliva,  the  mucous  membrane  of  the  mouth  is 
hot  and  dry.  Tiny,  white,  raised  dots  stud  the  mouth,  tongue,  and 
gums,  representing  the  muciparous  follicles,  with  here  and  there  a 
patch,  grayish-white  in  color,  overlying  an  affected  area  of  the  surface 
of  the  mouth.  Pain  may  be  so  great  as  to  cause  the  child  to  refuse  its 
nourishment,  and  become  ill  and  fretful  for  a  few  days  with  a  slight 
fever;  but,  as  a  rule,  there  are  no  constitutional  disturbances.  In 
some  instances  the  submaxillary  glands  become  enlarged;  but  the 
inflammation  is  rarely  severe,  and  there  is  never  tissue  necrosis  or 
ulceration. 

Prognosis. — In  healthy  children  this  is  very  favorable,  the  inflam- 
mation disappearing  within  a  few  days  under  proper  treatment. 
Delicate  children  may  become  seriously  ill  from  lack  of  nourishment 
and  gastro-intestinal  disturbances,  but  usually  recover  in  ten  days 
or  two  weeks. 

Treatment. — Cleanliness  of  the  mouth  is  of  more  practical  value  in 
the  treatment  of  stomatitis  than  any  other  procedure.  The  mouth 
should  be  washed  out  after  each  feeding  with  a  solution  of  sodium 
bicarbonate  and  sodium  borate,  using  fifteen  grains  of  each  to  the 
ounce  of  water;  or,  if  preferable,  a  25  per  cent,  solution  of  liquor 
alkalinus  antisepticus  may  be  used,  usually  with  prompt  and  satis- 
factory results.  If  the  inflammation  tends  to  persist,  the  mouth  may 
be  swabbed  with  silver  nitrate  solution,  0.5  per  cent.,  followed  by  a 


252  DISEASES  OF   THE  GAST RO-I XTESTI XAL   TRACT 

mouth  wash  of  cold  water,  and  a  piiicli  of  })oric  acid  or  ahun  dusted 
on  the  tongue.  If  the  mucous  membranes  of  the  nostrils  and  con- 
junctiva are  also  inflamed,  they  should  be  irrigated  with  the  same 
alkaline  washes  as  are  used  for  the  mouth.  The  child's  nutrition  must 
be  kept  up  by  full  feeding,  using  gavage  if  necessary,  and  a  child  of 
one  year  should  always  be  given  an  initial  purge  of  two  drams  of 
castor  oil. 


APHTHOUS    STOMATITIS   (HERPETIC    STOMATITIS). 

This  form  of.  stomatitis  is  characterized  by  the  formation  of  small, 
round,  yellowish,  superficial  ulcerations  on  the  mucous  membrane 
of  the  lips,  cheeks,  palate,  gums,  and  tongue,  and  is  always  accom- 
panied by  a  catarrhal  stomatitis. 

Etiology. — Aphthous  stomatitis  occurs  most  frequently  during  the 
first,  three  years  of  life.  The  actual  cause  is  unknowai;  a  nervous 
origin  has  been  suggested,  but  is  improbable.  Some  observers  believe 
it  to  be  an  infection  derived  from  the  bowels,  and  caused  by  toxins 
generated  in  contaminated  milk;  while  other  authorities  regard  it  as 
a  local  infection  of  the  mouth.  The  theory  of  the  infectious  nature 
of  aphthous  stomatitis  is,  to  my  mind,  the  most  probable.  From 
this  stand-point  we  may  regard  lack  of  proper  hygiene  of  the  mouth 
as  a  strongly  predisposing  factor,  since  aphthous  stomatitis  is  most 
common  during  that  period  of  infancy  ^^'hen  the  child  crawls  over 
the  floor  on  hands  and  knees,  and  puts  every  object  it  grasps  into  the 
mouth. 

The  French  theory  of  a  relation  between  aphthous  stomatitis  and 
the  foot-and-mouth  disease  of  cattle  which  is  transmitted  to  the 
child  through  the  medium  of  cow's  milk  I  consider  very  obscure,  and 
there  is  no  evidence  of  the  spread  of  this  disease  from  one  child  to 
another.  Most  cases  are  seen  in  connection  with  some  gastro-intes- 
tinal  disorder,  or  with  one  of  the  acute  infections  of  childhood;  but 
bacteriological  examination  of  the  oral  secretions  and  the  scrapings 
from  the  mouth  fail  to  reveal  any  organisms  other  than  those  found 
normally  in  the  mouth. 

Symptoms. — The  initial  lesions  are  small  macules,  usually  found  in 
the  anterior  part  of  the  mouth,  which  become  vesicles.  These  vesicles 
break  and  leave  small  ulcers,  at  first  of  a  grayish-white  color,  later 
turnmg  yellow  or  grayish-yellow  in  the  centre,  and  having  a  dark  red 
areola.  Ulceration  is  due  to  the  death  of  the  epithelium,  which 
becomes  elevated  above  the  vesicle  by  an  exudation  in  the  mucosa, 
therefore  the  ulcers  are  very  superficial.  They  vary  in  size  from  pin 
head  spots  to  patches  as  large  as  a  split  pea,  and,  in  some  instances, 
are  even  larger  as  the  result  of  the  coalescence  of  several  smaller  ulcers. 

Any  part  of  the  mouth  may  be  involved,  but  ulceration  is  most 
common  on  the  tongue  and  inner  smface  of  the  cheeks.  As  a  rule 
not  more  than  a  dozen  ulcers  are  visible  at  one  time,  although  fresh 
ulcers  may  appear  as  others  heal.     In  no  instance  does  the  necrosis 


THRUSH—SPRUE  253 

of  tissue  extend  further  than  the  mucous  membrane,  healing  always 
taking  place  without  scar  formation. 

The  gums  are  swollen,  the  tongue  coated,  the  mouth  is  hot  and 
dry,  although  there  is  hypersecretion  of  saliva.  Pain  is  sometimes 
very  severe,  which  discourages  the  taking  of  food.  There  is  usually 
a  somewhat  higher  fever  than  in  simple  acute  catarrhal  stomatitis, 
and  the  child  is  dull,  drowsy,  fretful,  and  restless.  The  stomach  and 
bowels  become  affected,  there  is  diarrhea,  and  sleep  is  broken  by 
intervals  of  restlessness;  so  that,  if  allowed  to  persist  very  long, 
aphthous  stomatitis  may  precipitate  a  serious  illness.  Enlargement 
of  the  submaxillary  glands  is  a  common  finding,  but  they  never  sup- 
purate, although  there  is  sometimes  pain  on  moving  the  jaw. 

Prognosis. — The  prognosis  of  aphthous  stomatitis  is  good,  and  the 
disease  ordinarily  runs  its  course  in  from  one  to  two  weeks,  ending 
in  spontaneous  recovery.  The  ulcerations  do  not  heal  so  quickly  in 
weaklings  and  marasmic  infants,  and  if  vigorous  treatment  is  not 
instituted,  a  mixed  infection  may  take  place  which  will  render  the 
case  much  more  serious. 

Treatment. — The  treatment  of  aphthous  stomatitis  differs  but  little 
from  that  of  the  acute  catarrhal  variety.  The  ulcerations  tend  to 
heal  more  quickly  if  touched  with  a  2  per  cent,  solution  of  silver 
nitrate  twice  daily,  following  each  application  by  a  mouth  wash  of 
cold  water.  After  each  feeding  the  mouth  should  be  washed  with 
a  25  per  cent,  solution  of  liquor  alkalinus  antisepticus,  or  an  alkaline 
wash  containing  15  grains  each  of  bicarbonate  of  soda  and  borate 
of  soda  to  the  ounce  of  water.  A  25  per  cent,  solution  of  hydrogen 
peroxide  used  three  times  a  day  as  a  mouth  wash  is  very  effective  in 
clearing  away  the  grayish-white  and  yellow  patches  of  necrotic  epithe- 
lium. As  in  the  treatment  of  catarrhal  stomatitis,  an  initial  dose 
of  two  drams  of  castor  oil  to  a  child  of  one  year  should  be  given, 
and  the  nourishment  kept  up  as  fully  as  possible.  Because  of  the 
hot  and  dry  condition  of  the  mouth,  food  will  be  taken  much  more 
readily  if  chilled  before  it  is  given,  and  the  sucking  of  small  pieces  of 
ice  affords  great  relief. 

THRUSH— SPRUE. 

Thrush  is  a  mycotic  infection  of  the  mucous  membrane  of  the 
mouth,  seen  most  frequently  in  children  of  the  poorer  classes,  and  is 
regarded  as  indicating  a  poor  state  of  the  nutrition  and  general  health 
rather  than  the  direct  result  of  poor  oral  hygiene.  The  fungus,  oidium 
albicans,  may  be  recovered  from  scrapings  of  the  mouth  in  every 
case.  It  occurs  in  the  yeast  form  and  the  mycelium,  and  under  the 
microscope  is  revealed  as  long  filaments,  which  frequently  branch 
and  unite  to  form  chains,  at  each  intersection  of  which  will  be  a  rounded 
cell,  or  several  cells,  containing  spores.  This  fungus  also  propagates 
by  filaments  from  conidia,  and  from  isolated  conidia.  In  certain 
respects  it  resembles  the  mould  fungus  and  the  yeast  fungus,  but 
cannot  be   satisfactorily    grouped   with  either  class.     As  a  rule,  the 


254  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

growth  is  confined  solely  to  the  mouth,  but  may  extend  to  the  nose, 
pharynx,  larynx,  or  even  to  the  stomach,  although  the  gastric  mucosa 
offers  a  very  unfavorable  site  for  tlirush,  since  this  fungus  thrives 
best  on  a  dry  surface. 

Etiology. — Infection  with  the  oidium  albicans  may  come  from  a- 
variety  of  sources,  but  the  most  important  predisposing  factor  is  a 
devitalized  condition  of  the  infant  or  child.  The  fungus,  itself,  is 
air  borne;  it  has  been  found  in  the  vaginal  secretion,  on  the  nipples 
of  the  breast,  and  has  been  isolated  from  the  mouths  of  normal  infants. 
Since  thrush  is  most  common  in  artificially  fed  babies,  it  is  probably 
carried  into  the  mouth  in  food  and  on  artificial  nipples,  which  have 
not  been  properly  cleansed  and  sterilized.  Although  the  devitalized 
mucous  membrane  in  the  mouths  of  weaklings  and  marasmic  children 
is  most  susceptible  to  thrush  infection,  yet  there  must  be  an  abrasion 
or  break  in  the  continuity  of  the  surface  of  the  mouth,  such  as  would 
be  produced  by  the  contact  of  an  improper  nipple,  before  the  fungus 
can  find  lodgment  and  grow.  The  disease  is  most  prevalent  in  hos- 
pitals and  foundling  asylums,  and  in  many  institutions  can  be  held 
in  check  only  by  careful  oral  hygiene.  It  is  rarely  seen  before  the 
baby  is  six  months  old. 

Symptoms. — The  first  manifestations  of  tlnush  are  tiny  white  spots 
like  cm-ds  of  milk  which  appear  on  the  tip  of  the  tongue,  the  mucous 
membrane  of  the  cheeks,  and  on  the  gums.  These  patches  are  adherent, 
grayish- white  in  color,  elevated  above  the  surrounding  tissue,  and 
vary  in  number  and  size  from  a  comparatively  few  small  patches,  in 
mild  cases,  to  a  number  of  large  areas  formed  by  the  coalescence  of 
many  smaller  lesions.  There  may  or  may  not  be  any  appreciable 
inflammation  of  the  surrounding  mucous  membrane;  but,  as  a  rule, 
there  is  a  mild  stomatitis,  the  mouth  is  dry,  and  the  gums  slightly 
inflamed  although  there  is  rarely  any  pain  apparent  to  interfere  with 
the  taking  of  food. 

Gastro-intestinal  disturbances  are  usually  present  at  the  height  of 
the  disease,  and  give  rise  to  nausea,  vomitmg,  diarrhea,  and  slight 
fever;  only,  however,  in  very  weak  and  anemic  children  do  actual 
lesions  of  the  stomach  occur,  and  these  cases  usually  end  fatally. 
When  the  growth  extends  merely  to  the  nasopharynx  and  esophagus, 
a  more  favorable  outcome  may  be  expected,  although  the  disease 
may  persist  for  a  greater  length  of  time  than  when  the  mouth  alone 
is  involved. 

Diagnosis. — The  diagnosis  of  thrush  is,  as  a  rule,  easily  made  when 
the  characteristic  grayish-white  patches  appear  throughout  the 
mouth,  accompanied  by  a  very  mild  stomatitis.  If  any  doubt  exists 
attempts  should  be  made  to  obtain  scrapings  from  the  mouth,  and 
these,  when  examined  under  the  microscope,  reveal  the  presence  of 
the  oidium  albicans.  On  casual  inspection  one  may  mistake  the 
small  white  patches  scattered  over  the  mouth  for  milk  curds;  but 
their  firm  attachment  to  the  mucous  membrane  shows  their  true 
nature,  while  then  ele^'ation  above  the  suiTOunding  surface  with  an 


ULCERATIVE  STOMATITIS  255 

absence  of  ulceration  serves  to  exclude  the  more  serious  forms  of 
stomatitis. 

Prognosis. — Thrush  in  the  normal  healthy  infant  is  of  little  conse- 
quence, and  usually  disappears  promptly  under  appropriate  treatment. 
It  is  the  poorly  nourished  child,  in  whom  thrush  is  complicated  by 
severe  gastro-intestinal  disturbances,  or  in  whom  it  appears  as  a  com- 
plication of  an  already  serious  digestive  derangement,  that  suffers 
greatly,  or  perhaps  dies,  from_  an  attack  of  mycotic  stomatitis. 

Treatment. — Prophylaxis  is  of  paramount  importance.  It  consists 
in  absolute  cleanliness,  not  only  of  the  infant's  mouth,  but  of  every- 
thing that  comes  in  contact  with  the  child's  mouth  or  food.  Thus, 
the  nurse's  hands,  the  mother's  breast,  the  nursing  bottle,  and  the 
nipple  should  be  kept  as  nearly  sterile  as  possible,  and  the  mouth 
should  be  cleansed  after  each  feeding  by  giving  the  infant  a  table- 
spoonful  of  water. 

These  precautions  should  be  instituted  immediately  on  the  appear- 
ance of  thrush;  in  addition,  the  mouth  should  be  washed  out  three 
times  daily  with  a  saturated  solution  of  boric  acid,  using  a  cotton 
swab  when  attempting  to  remove  the  various  patches,  but  this  must 
be  done  very  carefully,  lest  the  mucous  membrane  be  abraded.  When 
there  are  abrasions  or  superficial  ulcerations,  a  2  per  cent,  solution 
of  silver  nitrate  should  be  applied  daily.  If,  despite  treatment,  heal- 
ing is  delayed,  it  is  advisable  to  discontinue  the  use  of  an  artificial 
nipple,  and  substitute  dropper  feeding  or  gavage  until  there  is 
improvement. 

Gastro-intestinal  complications  should  be  met  by  careful  regula- 
tion of  the  diet,  restriction  of  the  amount  of  food,  and  an  initial  purge 
of  castor  oil,  two  drams  to  a  child  of  one  year.  The  following  pre- 
scription is  useful,  both  for  its  tonic  effect  and  its  local  beneficial 
action  on  the  mouth,  and  may  be  given  with  little  reservation,  regard- 
less of  the  condition  of  the  stomach: 

I^ — Tinct.  ferri  chloridi _  .      .  3J 

Potassii  chloratis gr.  xxx 

Glycerini 3iv 

Aqua q.  s.  f  Biij 

Sig. — 5J  ill  aqua  every  three  hours. 

ULCERATIVE    STOMATITIS. 

Ulcerative  stomatitis  is  one  of  the  most  severe  inflammations  of  the 
mouth  seen  in  childhood,  and  occurs  chiefly  in  the  children  of  the 
poor,  neglect  being  an  important  factor  in  its  etiology.  It  does  not 
appear  until  dentition  has  been  established.  The  ulcerative  process 
is  always  first  noticed  at  the  line  of  junction  of  the  gums  and  teeth, 
the  gums  of  the  lower  jaw  being  most  commonly  the  site  of  the  first 
ulcers,  which  rapidly  extend  along  the  teeth,  and  may  involve  the 
alveolus. 

Etiology. — Vlcerative  stomatitis  is  very  rare  in  private  practice. 
The  majority  of  cases  are  observed  in  dispensary  patients  and  inmates 


25G  DISEASES  OF   THE  G ASTRO-INTESTINAL   TRACT 

of  hospitals  and  asylums;  therefore,  lack  of  proper  oral  hygiene, 
together  with  a  poor  state  of  general  health,  may  be  considered  an 
essential  factor  in  its  production.  That  improper  diet  also  may  be  a 
cause  is  apparent  from  the  fact  that  it  accompanies  scurvy.  It  may 
also  occur  as  a  sequel  of  typhoid  fever,  pneumonia,  and  the  acut« 
contagious  diseases  of  childhood.  Formerly,  ulcerative  stomatitis 
was  not  infrequently  due  to  the  ingestion  of  metallic  poisons,  among 
which  mercury,  lead,  and  phosphorus  were  the  most  common;  but 
with  the  exception  of  mercurial  poisoning,  this  is  now  quite  rare. 

Carious  teeth  form,  perhaps,  the  most  frequent  exciting  cause; 
but  there  must  also  be  a  devitalized  condition  of  the  gums,  due  to  the 
poor  physical  condition  of  most  of  these  children.  Some  observers 
believe  this  form  of  stomatitis  to  be  contagious,  and  claim  that  it 
may  be  transmitted,  but  this  theory  is  not  borne  out  to  any  great 
extent,  although  epidemics  of  ulcerative  stomatitis  have  been  observed. 
Bernheim  and  Pospischill  made  a  bacteriological  study  of  a  number 
of  cases,  and  from  all  but  two  of  them  a  fusiform  bacillus,  resembling 
the  bacillus  of  diphtheria,  and  a  spirillum  were  isolated,  both  being 
present  in  each  case,  one  or  the  other  always  predominating. 

Pathology. — ^At  the  onset  of  this  disease  the  gums,  usually  about 
the  lower  incisors,  become  swollen  and  red;  as  the  swelling  increases, 
the  teeth  may  be  almost  covered  by  the  gums,  which  become  very 
spongy,  are  of  a  dark  red  color,  and  bleed  when  touched.  Ulcera- 
tions now  form  at  the  junction  of  the  gums  and  teeth,  spreading 
quickly  along  the  whole  line  of  junction,  but  usuall\'  confined  to  one 
jaw. 

In  severe  cases  the  teeth  may  become  exposed  and  loosened,  the 
lips  and  cheeks  ulcerated;  but  the  process  is  always  limited  to  the 
oral  cavity,  the  entire  buccal  mucous  membrane  showing  an  acute 
catarrhal  inflammation.  The  junction  of  the  gums  and  teeth  is 
usually  represented  by  a  ridge  of  yellowish  necrotic  granulations, 
bathed  in  a  mucopurulent  exudation.  In  some  cases  the  tooth  sockets 
may  become  involved,  and  the  necrotic  process  extend  to  the  peri- 
osteum of  the  alveolar  process,  and  even  to  the  jaw-bone. 

Symptoms. — Pain  is  usually  so  severe  when  food  is  taken  into 
the  mouth  that  feeding  is  quite  difficult.  The  tongue  is  coated,  the 
breath  foul,  salivation  increased,  and  neglected  cases  frequently  show 
an  eczema  of  the  lips  due  to  the  constant  dribbling  of  blood-streaked 
saliva  mixed  with  pus.  In  very  young  children,  there  is  usually  mod- 
erate fever,  and  because  of  lack  of  nourishment  they  become  restless, 
irritable,  much  weakened,  and  exhausted.  On  inspection  of  the 
mouth  the  swollen,  inflamed,  and  bleedmg  gums  are  plainly  visible; 
careful  investigation  may  reveal  loosened  teeth  and,  perhaps,  other 
ulcerations  on  the  inside  of  the  lips,  cheeks,  and  even  upon  the 
palate  and  tonsils.  It  is  only  in  most  severe  cases  that  the  alveolar 
periosteum  and  the  jaw-bone  are  found  to  be  necrotic. 

Diagnosis. — The  diagnosis  is,  in  most  instances,  readily  made  from 
the  condition  of  the  gums  and  the  extreme! v  foul  breath.    The  mild- 


GANGRENOUS  STOMATITIS  257 

ness  of  the  constitutional  symptoms,  in  comparison  with  the  severity 
of  the  local  affection  in  the  mouth,  is  also  an  aid  in  diagnosis. 

Bednar's  aphthae  may  be  suggested,  but  if  one  recalls  the  fact  that 
in  this  rare  affection  the  ulcers  are  found  only  on  either  side  of  the 
raphse  over  the  hamular  process  of  the  palate  bone,  no  mistake  will 
be  made,  since  in  ulcerative  stomatitis  the  ulcerations  may  be  found 
anywhere  within  the  mouth.  Gangrenous  stomatitis  may  be  differen- 
tiated from  the  ulcerative  form  by  the  severity  of  the  constitutional 
symptoms,  and  the  localization  of  the  lesion  to  one  particular 
area. 

Prognosis. — In  this  disease,  as  in  the  other  forms  of  stomatitis,  the 
course  and  prognosis  depend  to  a  great  extent  upon  the  vitality  of 
the  child.  Fairly  well-nourished  children  should  show  improvement 
within  a  week  after  treatment  is  instituted;  but  anemic  and  mar- 
asmic  infants  may  not  recover  from  ulcerative  stomatitis  for 
months  although,  in  the  majority  of  cases,  the  final  outcome  is 
favorable. 

Treatment. — In  the  treatment  of  ulcerative  stomatitis,  the  first 
consideration  should  be  directed  to  finding  the  cause  of  the  attack, 
and  removing  it.  The  mouth  should  be  kept  absolutely  clean  by  the 
use  of  antiseptic  washes  and  cleansing  agents  such  as  a  25  per  cent, 
solution  of  hydrogen  peroxide,  or  1  to  5000  solution  of  potassium 
permanganate,  or  a  saturated  solution  of  potassium  chlorate.  The 
ulcerations  should  be  touched  daily  with  alum,  or  a  10  per  cent,  nitrate 
of  silver  solution. 

Potassium  chlorate  is  also  valuable  given  internally  in  ulcerative 
stomatitis,  if  its  administration  is  properly  carried  out.  My  plan 
has  been  to  give  a  child  of  two  or  three  years  two  grains  every  two 
hours  the  first  day,  and  to  reduce  the  total  daily  quantity  one-half 
each  succeeding  day,  as  improvement  is  observed.  If  necrosis  of  the 
jaw  is  suspected,  the  loosened  teeth  should  be  extracted,  the  jaw-bone 
carefully  examined,  and  treated  surgically  if  necessary.  Because  of 
the  poor  physical  condition  of  these  children,  they  should  be  placed 
in  the  most  healthful  environment,  w^ith  fresh  air,  smishine,  and 
nourishing  food  in  abundance.  If  due  to  scurvy,  orange  juice  should 
be  given  daily;  if  anemia  be  marked,  full  doses  of  the  syrup  of  ferrous 
iodide,  or  an  amount  of  iron  equal  to  this  in  any  other  form,  will 
materially  promote  recovery. 

GANGRENOUS    STOMATITIS. 

Gangrenous  stomatitis,  cancrum  oris,  or  noma  is  a  rare  disease 
of  the  mouth  which  affects  children  of  the  poorer  classes,  and  is 
characterized  by  the  appearance  of  a  small  inflammatory  spot  on  the 
cheek  which  quickly  becomes  necrotic,  extends  with  tremendous 
rapidity,  and  may  end  fatally  in  a  few  days.-  This  same  disease  is 
occasionally  observed  on  the  vulva,  and  more  rarely  on  the  anus  and 
prepuce. 
17 


258 


DISEASES -OF  THE  GASTRO-INTESTINAL   TRACT 


Etiology. — Gangrenous  stomatitis  is  most  frequently  seen  in  insti- 
tutions, being  almost  unknown  in  private  practice.  It  is  usually  the 
sequel  to  a  severe  illness,  perhaps  one  of  the  acute  infections,  par- 
ticularly measles;  a  predisposing  factor  is  debility  from  any  cause. 
Although  several  organisms  have  been  described  in  connection  with 
cancrum  oris,  among  them  a  fusiform  bacillus,  a  spirochete,  and  the 
streptococcus,  the  specificity  of  any  one  particular  germ  has  not 
been  satisfactorily  established.  In  many  cases  catarrhal  or  ulcerative 
stomatitis  has  been  the  precursor  of  the  disease.  It  is  seen  most 
frequently  in  that  period  of  childhood  between  the  first  and  second 
dentitions,  and  is  as  common  in  boys  as  in  girls. 

Symptoms. — Following  measles,  or  any  other  acute  infectious  dis- 
ease, or  a  long  debilitating  illness  which  has  been  complicated  by 
catarrhal  or  ulcerative  stomatitis,  the  child  with  beginning  gan- 
grenous stomatitis  is  at  once  conspicuous  by  the  foul  gangrenous  odor 


Fig.  28. — Gangrenous  stomatitis. 


of  the  breath.  On  mspection  of  the  mouth,  a  spot  of  beginning  necro- 
sis will  usually  be  found  on  the  inner  side  of  one  cheek,  this  par- 
ticular area  of  mucous  membrane  being  of  a  darker  shade  than  the 
surrounding  tissue.  A  bleb  forms  on  the  inside,  and  a  corresponding 
brawaiy  swelling  on  the  outer  surface  of  the  cheek.  The  gangrenous 
spot  increases  rapidly  in  size,  and  the  centre  sloughs  away,  leaving 
a  dark,  necrotic,  ulcerating  surface  which  may  result  in  perforation 
of  the  cheek. 

In  severe  cases,  the  gums  become  necrotic,  the  teeth  loosen  and 
fall  out,  even  the  jaw-bone  becomes  necrosed.  A  fetid  discharge 
covers  the  aflFected  parts,  and  emits  a  foul,  penetrating  odor  which* 
is  characteristic  of  the  disease.  As  a  rule  pain  is  very  slight,  even 
with  perforation,  and  thrombosis  of  the  vessels  at  the  margin'  of  the 
ulcer  inhibits,  bleeding. 

The  constitutional  symptoms  vary  somewhat,  but  become  severe; 


GANGRENOUS  STOMATITIS  259 

fever,  as  a  rule,  is  moderate;  the  child  is  dull,  apathetic,  extremely 
depressed  or  prostrated,  and  may  become  delirious  because  of  the 
severe  toxemia,  further  evidence  of  which  is  the  extremely  feeble 
action  of  the  heart.  The  lymph  nodes  of  the  face  and  neck  show 
general  enlargement,  diarrhea  is  always  present,  and  the  disease 
usually  comes  to  a  fatal  termination  by  septic  pneumonia. 

Diagnosis. — The  diagnosis  of  gangrenous  stomatitis  is  easily  made 
when  the  disease  is  well  established;  but,  at  the  onset,  the  initial 
lesion  is  extremely  difficult  to  differentiate  from  simple  ulcer  of  the 
mouth.  Anthrax  may  be  excluded  by  the  history  of  the  case  and  by 
bacteriological  examination  of  scrapings  of  the  mouth. 

Prognosis. — ^The  prognosis  of  cancrum  oris  is  unfavorable;  few 
children  survive;  therefore  only  slight  hope  of  recovery  can  be  held 
out  to  the  parents. 

Treatm.ent. — Prophylaxis  is  the  most  important  element  in  any  treat- 
ment which  can  be  said  to  be  effective.  The  mouth  should  always 
receive  the  utmost  attention  during  the  course  of  any  debilitating 
disease.  It  should  be  cleansed  very  gently,  for  too  vigorous  cleansing 
which  results  in  abrasions  of  the  mucous  membrane  is  more  harmful 
than  none  at  all.  If  ulceration  appears,  the  mouth  should  be  care- 
fully inspected  daily  so  that,  at  the  first  indication  of  approaching 
gangrene,  the  necrotic  tissue  may  be  widely  excised.  If  necrosis  be 
already  advanced  and  extensive,  the  case  is  desperate ;  but  an  attempt 
may  be  made  to  cauterize  the  edge  of  the  slough,  going  well  into  the 
living  tissue  at  all  points.  For  this  purpose  the  actual  cautery  must 
be  used,  caustics  and  other  cauterizing  agents  being  of  no  value 
whatsoever. 

Attempts  have  been  made  to  stop  the  ravages  of  this  disease  by 
means  of  the  a-ray,  incandescent  lamps,  and  injections  of  either  the 
perchloride  of  mercury,  carbolic  acid,  or  tincture  of  iodin  into  the 
tissues  at  points  in  advance  of  the  approaching  necrosis;  but  radical 
surgical  procedures,  such  as  wide  excision  of  the  gangrenous  tissue, 
multiple  tooth  extraction,  and  curettage  of  the  jaw-bone  have  been 
more  successful,  when  the  condition  of  the  patient  warranted  them. 
The  mouth  should  be  cleansed  frequently  with  a  25  per  cent,  solution 
of  liquor  alkalinus  antisepticus,  and  the  ulcerated  surface  protected 
by  a  dressing. 

Although  sometimes  very  difficult  to  prevent  it,  the  child's  strength, 
if  possible,  should  not  be  allowed  to  fail.  It  should  be  given  the 
most  nourishing  liquid  food  in  small  quantities  every  two  hours,  and 
be  kept  in  the  sunshine  and  fresh  air  as  long  as  the  slightest  hope  of 
recovery  is  entertained.  Stimulation  is  necessary  in  every  case,  and 
20  or  30  drops  of  brandy  may  be  given  a  child  of  two  years,  every 
two  hours;  if  borne  by  the  stomach,  a  half  teaspoonful  of  the  mixture 
of  iron,  quinine,  and  strychnine  should  also  be  given  three  times  a  day. 
In  recent  years,  antistreptococcic  and  antidiphtheritic  serum  have 
been  used  to  combat  cancrum  oris,  but  with  little  appreciable  result, 


2GU  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

PYORRHEA    ALVEOLARIS. 

Pyorrhea  alveolaris  is  a  subacute  or  chronic  inflammation  of  the 
pericemental  membrane,  and  may  appear  at  any  time  after  the  erup- 
tion of  the  teeth.  The  exciting  cause  is  ahvays  of  bacterial  nature 
but  the  primary  underlying  factor  of  pyorrhea  in  childhood  is  gastro- 
intestinal toxemia.  Bacterial  invasion  is  favored  by  irritation  pro- 
duced by  the  tartar  deposited  on  the  teeth  and  gums,  and  may  also 
be  brought  on  by  trauma  to  the  gums  or  by  chemical  and  mechanical 
irritation. 

Symptoro.s. — The  onset  of  pyorrhea  alveolaris  is,  as  a  rule,  sudden, 
and  pain  is  usually  the  first  sjTnptom.  The  gums  become  swollen, 
are  painful  on  pressure,  and  the  teeth  are  loosened  by  recession  of  the 
gum  margin.  On  inspection  of  the  mouth  a  purulent  discharge  may 
be  obser^'ed  to  exude  from  the  gum  margin,  and  this  accounts,  in  a 
measure,  for  the  foul  breath  and  coated  tongue  which  these  children 
present.  In  most  instances  this  pus  is  swallowed,  and  by  its  presence 
either  gives  rise  to  fermentation  of  the  stomach  or  to  direct  absorption 
of  the  toxins  into  the  child's  system.  The  effect  of  pyorrhea  locally 
is  to  favor  to  a  great  degree  the  entrance  and  growth  of  many  patho- 
genic organisms,  particularly  the  bacilli  of  influenza  and  diphtheria. 

Treatment. — The  child  affected  with  pyorrhea  alveolaris  should 
be  sent  to  see  a  dentist  in  order  that  the  teeth  may  be  thoroughly 
cleansed  and  deposits  of  tartar  removed,  after  which  an  antiseptic 
mouth  wash  composed  of  equal  parts  of  hydrogen  peroxide  and 
extract  of  witch  hazel  should  be  used  at  least  every  two  hours  the  first 
day  or  so,  and  less  frequently  thereafter.  The  diet  should  not  be 
reduced  in  amount,  but  the  food  must  be  so  soft  that  mastication  is 
unnecessary,  lest  the  gums  become  traumatized  by  the  act  of 
chewmg. 

\Yhen  pyoirhea  does  not  respond  to  the  foregoing  treatment,  a 
culture  should  be  obtained  from  the  discharge,  and  an  autogenous 
vaccine  be  made,  the  dosage  of  which  would  depend  largely  upon 
the  organism  grown  and  the  eft'ect  of  the  treatment  outlined  UDon  the 
disease.  Recent  observations  of  the  beneficial  eft'ect,  in  most  cases, 
of  the  hypodermic  administration  of  emetin  hydrochloride,  seem  to 
recommend  a  trial  of  this  therapeutic  measure. 

UVTJLITIS. 

Acute  inflammation  of  the  uvula  is  rare  during  childhood,  and 
practically  unknown  in  infants.  Children  with  congenital  elongation 
of  the  uvula  are  especially  predisposed  to  attacks  of  uvulitis;  and, 
since  each  attack  still  further  elongates  the  organ,  recurrent  uvulitis 
is  quite  common. 

Etiology. — T'vulitis  not  infrequently  occurs  in  association  with  gastro- 
intestinal disturbance  and  rachitis,  and  in  rare  instances  may  be  pro- 
duced b>'  the  ingestion  of  liot  liquids,  strong  acids,  or  alkalies.     The 


ESOPHAGITIS  261  - 

most  common  cause  of  uviilitis  is  the  extension  of  an  iiifiammatory 
process  in  the  pharynx  or  tonsils. 

Symptoms. — The  most  distinctive  symptom  of  u\'uhtis  is  a  persistent 
unproductive  cough,  due  to  an  attempt  to  reheve  the  irritation  pro- 
duced by  the  pressure  of  the  uvula  on  the  base  of  the  tongue,  fauces, 
or  upper  part  of  the  larynx.  There  is  also  a  constant  desire  to  swallow, 
even  though  swallowing  be  painful,  for  the  swollen  uvula  feels  like 
a  foreign  body  in  the  pharynx,  and  in  severe  cases  it  may  attain  such 
a  size  that  the  oropharyngeal  opening  is  occluded,  thus  causing  dyspnea 
and  attacks  of  suffocation.  When  the  swelling  of  the  uvula  reaches 
these  proportions,  it  interferes  with  the  taking  of  food,  and  the  child 
may  become  weak  and  exhausted  from  lack  of  nourishment.  Other 
constitutional  symptoms  are  rare. 

Diagnosis. — The  diagnosis  of  uvulitis  is  very  simple,  and  readilv 
made  by  inspection  of  the  mouth,  which  reveals  the  swollen,  boggy, 
edematous  uvula,  very  much  altered  in  shape,  and  so  enlarged  as  to 
be  in  contact  with  the  base  of  the  tongue  and  the  fauces. 

Treatment.- — At  the  onset  of  inflammation,  uvulitis  may  sometimes 
be  aborted  by  swabbing  the  uvula  every  hour  with  a  1  to  20,000 
solution  of  adrenalin  chloride.  After  the  uvula  has  become  edematous, 
adrenalin  has  little  permanent  effect;  but  the  swelling  may  be  greatly 
relieved  by  the  application  of  a  2  per  cent,  solution  of  tannic  acid  three 
times  daily.  A  gargle  of  Dobell's  solution  should  be  used  every  three 
hours;  if  the  child  be  too  young  to  gargle,  this  solution  may  be  sprayed 
upon  the  throat.  Great  relief  will  be  afforded  by  allowing  the  child 
to  suck  small  pieces  of  ice,  and  by  cold  applications  to  the  neck. 

In  mild  cases  of  uvulitis  the  foregoing  measures  are  usually  effectual; 
but  when  swelling  of  the  organ  becomes  so  great  as  to  produce  dyspnea, 
more  radical  treatment  is  often  necessary.  Multiple  puncture  of  the 
uvula  with  a  short  bistoury  or  double-cutting  aspirating  needle  is 
the  quickest  and  most  satisfactory  method  of  relieving  the  tension, 
and  is  not  attended  by  any  danger.  If  the  inflammation  shows  a 
tendency  to  chronicity,  the  tip  of  the  uvula  should  be  excised. 


DISEASES   OF  THE   ESOPHAGUS. 


ESOPHAGITIS. 

Acute  inflammation  of  the  esophagus  is  much  more  rare  in  children 
than  in  adults.  Occasionally  it  is  produced  by  the  extension  of  inflam- 
matory processes  in  the  mouth  or  pharynx;  but  usually  it  is  due 
either  to  the  ingestion  of  strong  acids  or  alkalies,  or  to  the  impaction 
of  a  foreign  body  which  the  child  has  attempted  to  swallow. 

Symptoms. — The  symptoms  of  acute  esophagitis  are  largely  depen- 
dent upon  the  cause.    If  there  be  but  slight  injury  to  the  mucous  mem- 


262  DISEASES  OF   THE  GASTRO-INTESTINAL  TRACT 

}>rane,  there  is  merely  a  little  pain  on  swallowing  and  slight  elevation 
of  temperature  for  a  few  days,  but  when  strong  acids  or  corrosi^'es 
have  been  swallowed  the  symptoms  are  most  severe,  and  death  may 
ensue  in  a  few  hom's.  The  child  is  usually  prostrated.  It  vomits 
shreds  of  bloody  mucus.  Thirst  is  extreme.  There  is  severe  burning 
pain  under  the  sternum,  and  every  attempt  to  swallow  causes  such 
suffering  that  the  taking  of  liquids  is  exceedingly  difficult.  If  the 
patient  survives  this  period  of  acute  symptoms,  there  still  remains 
the  danger  of  edema  of  the  glottis  which  sometimes  comes  on  during 
the  succeeding  two  days.  Not  until  a  year  has  elapsed  may  we  feel 
sure  that  no  ill  effects  will  follow;  for  stricture  of  the  esophagus  may 
appear  at  any  time  from  two  weeks  to  several  months  after  the 
accident. 

Treatment. — The  mild  form  of  esophagitis  heals  spontaneously 
within  a  few  days,  hence  treatment  is  unnecessary  except  the  restric- 
tion of  the  diet  to  bland  liquids  at  a  moderate  temperature.  Cases 
due  to  poison  should  receive  antidotes  immediately,  and  an  effort 
be  made  to  empty  the  stomach.  Stimulation  is  often  necessary,  and 
the  strength  may  be  supported  by  hypodermic  injections  of  morphine 
sulphate,  gr.  to;  and  atropine  sulphate,  gr.  tIt  (for  a  child  of  five 
years),  also  by  the  rectal  injection  of  brandy,  oij>  in  an  ounce  of  black 
coffee.  This  may  be  repeated  every  three  hours  until  all  danger  from 
collapse  is  passed,  and  then  the  child  should  be  closely  watched  for 
signs  of  edema  of  the  glottis.  Nourishment  should  be  kept  up  by 
means  of  nutrient  enemata,  and  codeine  sulphate,  gr.  y^^  may  be 
given  for  the  relief  of  pain.  If  stricture  occurs  as  a  sequel,  surgical 
intervention  is  necessary. 

RETROESOPHAGEAL   ABSCESS. 

Retroesophageal  abscess  is  a  very  rare  affection,  caused  either  by 
the  breaking  dowTi  of  the  retroesophageal  lymph  nodes  or  by  the 
extension  of  a  suppiu-ative  process  due  to  Pott's  disease.  It  is  most 
frequently  seen  in  association  with  tuberculosis,  but  may  follow 
measles,  scarlet  fever,  or  diphtheria. 

Symptoms. — Among  these  are  an  irritating  spasmodic  cough  and  a 
decided  change  in  the  voice.  The  breathing  is  stertorous.  Dyspnea 
occurs  spasmodically,  and  is  most  marked  on  inspiration.  The  neck 
is  swollen  externally,  and  all  the  cervical  glands  are  greatly  enlarged. 
The  temperature  often  runs  up  to  102.5°  F.  or  above,  and  the  pulse 
and  respiration  are  accelerated. 

Prognosis. — In  retroesophageal  abscess  the  prognosis  is  unfavorable. 
INIost  cases  die  from  pressure  on  the  pneumogastric  nerve  or  rupture 
of  the  abscess  into  adjacent  structures.  iVn  instance  is  reported  of 
recovery  after  rupture  of  such  an  abscess  into  the  esophagus. 

Treatment. — The  treatment  is  surgical;  the  abscess  should  be  opened 
and  drained.  If  the  child  is  tuberculous,  it  should  be  removed  from 
any  crowded  surroundings  and  sent  to  the  seashore.    The  diet  should 


PLATE  II 


stricture  of  the  Esophagus  in  a  Child  Aged  Two  and  a  Half 
"Years,  due  to  Swallo\ving  Lye. 

R.,  right  side;  L.,  left  side.  1,  dilated  portion  of  esophagus  above 
eonstrieted  portion;  2,  niarked  irregularity  in  lumen  of  esophagus; 
8,  narrowed  portion  of  lumen;    4,  the  stomach. 


VOMITING  263 

be  so  adjusted  as  to  consist  of  most  nourishing  food,  and  a  tonic, 

such  as  cod-Hver  oil  or  the  syrup  of  the  iodide  of  iron,  may  be  given 
if  the  stomach  is  not  upset  by  this  medicine. 


DISEASES  OF  THE  STOMACH  AND  INTESTINES. 

VOMITING. 

Vomiting,  although  merely  a  symptom,  occurs  so  frequently  in 
infancy  and  childhood,  and  arises  from  such  a  variety  of  causes,  that 
special  discussion  of  this  subject  is  warranted. 

In  Early  Infancy. — The  newborn  infant  may  vomit  immediately 
after  each  nursing,  even  though  perfectly  healthy.  This  is  usually 
caused  by  the  infant  swallowing  the  breast  milk  too  quickly  or  by 
overfeeding,  and  is  a  conservative  measure  on  the  part  of  the  stomach 
to  prevent  overtaxation  of  the  digestive  organs.  Various  reasons 
have  been  adduced  to  explain  this  symptom,  and  it  is  probable  that 
other  factors  may  be  responsible  for  vomiting  in  the  breast-fed  infant, 
since  regulation  of  the  quantity  and  the  time  of  feeding  does  not 
always  correct  the  condition. 

The  stomach  of  an  infant,  lying  as  it  does  in  an  almost  upright 
position  so  that  it  forms  a  nearly  continuous  line  with  the  esophagus, 
is  easily  emptied  by  slight  pressure  such  as  might  be  created  by  the 
movements  of  the  diaphragm  during  respiration.  There  is  neither 
nausea  nor  epigastric  pain  in  this  form  of  vomiting;  the  milk  usually 
returns  only  slightly  changed  or  curdled;  and,  although  the  condition 
may  persist,  no  appreciable  loss  of  weight  results.  It  is  always  well 
to  investigate  the  feeding  of  an  infant  in  whom  this  form  of  vomiting 
is  observed;  but  if  correction  and  regulation  of  the  nursing  do  not 
relieve  it,  no  further  treatment  can  be  instituted,  and  the  condition 
may  with  safety  be  allowed  to  continue,  as  it  will  cease  spontaneously 
in  due  time. 

Symptomatic  Vomiting. — Vomiting  in  later  infancy  and  in  childhood 
is  always  significant  of  some  disorder,  and  should  never  be  regarded 
or  treated  as  an  independent  affection.  In  extremely  few  cases  it 
may  be  said  to  have  become  a  habit,  the  attack  being  apparently  a 
voluntary  act  on  the  part  of  the  child  during  a  crying  spell  or  fit  of 
anger.  By  far  the  most  common  cause  of  vomiting  is  indigestion, 
either  chronic  or  acute,  and  when  due  to  this  cause  it  is  accompanied 
by  pain  in  the  stomach  as  well  as  nausea.  The  vomited  material 
indicates  clearly  the  source  of  irritation,  for  it  is  composed  of  undi- 
gested sour-smelling  food  or  curds  of  milk.  This  form  of  vomitmg 
should  receive  careful  attention  and  treatment  from  its  very  begin- 
ning, since  it  is  indicative  of  digestive  disturbances  which,  if  allowed 
to  continue,  ma}"  become  chronic. 


261  DISEASES  OF   THE  GASTRO-INTESTINAL  TRACT 

In  young  children  any  cough,  if  at  all  severe,  will  produce  vomiting, 
and  in  pertussis,  especially,  the  child  vomits  at  each  paroxysm. 
Reflex  vomiting  is  also  provoked  by  u-ritation  of  the  pharynx  from 
an  elongated  nipple,  by  the  habit  of  hand  sucking,  or  by  eye-strain, 
earache,  dentition,  or  intestinal  worms.  The  projectile  vomiting 
of  meningitis  is  reflex  in  character,  and  although  it  commonly  appears 
at  the  onset  of  the  illness  it  rarely  recurs.  The  same  form  of  vomiting 
is  observed  in  cases  of  brain  tumor  and  in  cerebellar  disease,  but 
without  other  signs  of  digestive  disturbance. 

Aside  from  indigestion,  perhaps  the  most  common  cause  of  vomit- 
ing is  intestinal  derangement,  which  need  not  necessarily  be  of  inflam- 
matory nature,  since  it  often  results  from  the  absorption  of  toxins 
in  the  upper  and  lower  bowel.  Vomiting  is  often  the  first  symptom 
of  intestinal  obstruction,  whether  from  volvulus,  intussusception, 
or  fecal  impaction,  and  persists  until  the  obstruction  is  relieved, 
becoming  stercoraceous  in  the  end.  In  appendicitis  also  it  is  a  promi- 
nent symptom  at  the  onset,  but  does  not  continue  throughout  the 
attack  unless  peritonitis  sets  in,  and  in  peritonitis  it  invariably  indi- 
cates extreme  irritability  of  the  visceral  peritoneum.  Obstruction 
higher  up  in  the  alimentary  canal,  and  commonly  at  the  pylorus  or 
esophagus,  is  also  accompanied  by  vomiting  which,  however,  is  more 
of  the  nature  of  regurgitation.  In  pyloric  stenosis  particularly,  there 
is  constant  regurgitation  of  small  quantities  of  food  with  intermittent 
periods  in  which  the  amount  of  vomitus  is  far  in  excess  of  the  quantity 
of  food  taken  at  the  preceding  nursing,  since  it  represents  the  residue 
of  several  previous  feedings  which  have  been  retained  by  the  greatly 
dilated  stomach. 

Some  children,  and  many  infants,  vomit  whenever  there  is  an 
elevation  of  the  body  temperature  of  2°  or  3°,  regardless  of  the  cause 
of  the  pyrexia,  and,  in  most  of  the  acute  infections,  vomiting  is  one 
of  the  premonitory  symptoms.  There  undoubtedly  occurs  a  neurotic 
form  of  vomiting  which  is  induced  by  excitement,  fright,  fear,  or 
fatigue,  especially  in  children  with  a  tainted  nervous  heredity.  There 
are  other,  and  trivial,  causes  of  vomiting  which  have  not  been  dis- 
cussed; but,  before  attributing  vomiting  to  some  slight  incident  or 
occurrence,  the  patient  should  be  thoroughly  examined  for  signs  of 
one  of  the  grave  diseases  which  may  possibly  be  present. 

Cyclic  Vomiting. — Cyclic  vomiting  is  comparatively  rare  and  is 
peculiar  to  children.  As  the  term  implies,  there  are  periodical  attacks 
of  vomiting  which  occur  at  intervals  of  weeks  or  months,  without 
other  signs  of  gastric  disturbance.  This  condition  is  of  such  impor- 
tance that  it  is  described  as  a  distinct  disease,  although  it  has  not 
been  proven  to  be  a  primary  affection  of  the  stomach.  During  the 
attacks  the  stomach  is  extremely  intolerant  to  food  of  any  kind  or 
e\'en  water,  and  prostration  is  sudden  and  extreme. 

Etiology. — The  direct  cause  of  cyclic  vomiting  is  unknown,  but 
from  observation  of  a  number  of  cases  it  is  evident  that  a  variety  of 
factors  are  operative  in  its  production.    Feeding  seems  to  be  of  minor 


VOMITING  265 

importance,  since  the  affection  is  observed  in  children  whose  diet  is 
ideal;  hence  it  may  be  assumed  in  the  majority  of  cases  that  the 
impulse  arises  from  a  source  outside  the  stomach,  in  further  support 
of  which  assumption  is  the  apparent  absence  of  gastric  derangement 
in  the  intervals  between  the  attacks.  A  great  many  children  w^ho 
suffer  from  cyclic  vomiting  are  of  a  neurotic  disposition,  and  since 
it  practically  occurs  only  during  childhood,  when  the  nervous  system 
is  as  yet  unstable,  it  is  quite  possible  that  a  nervous  element  is  active 
in  its  causation. 

The  fact  that  in  a  number  of  instances  acetone  and  diacetic  acid 
have  been  demonstrated  in  the  urine  of  these  patients,  and  that  the 
breath  has  had  a  pear-like  odor,  has  firmly  supported  the  view  that 
cyclic  vomiting  is  a  result  of  acidosis.  This  theory  is  further  borne 
out  by  the  effects  of  alkaline  treatment.  It  is  quite  probable  that  in 
cyclic  vomiting  we  have  the  symptom-complex  of  gastro-intestinal 
lithemia  due  to  an  increased  acidity  of  the  body  fluids  as  a  result  of 
disturbed  metabolism,  and  the  importance  of  gastro-intestinal  auto- 
intoxication as  a  causative  factor  cannot  be  overlooked,  since  in  many 
of  these  children  there  is  a  history-  of  constipation  for  long  periods 
before  each  attack. 

Symptoms. — An  attack  of  cyclic  vomiting  usually  lasts  from  one  to 
three  or  four  days,  during  which  time  there  are  intervals  of  from 
three  to  six  hours  in  which  vomiting  ceases,  only  to  be  repeated,  until 
the  attack  is  over.  The  vomitus,  at  first,  is  com'posed  of  undigested 
food,  although  little  or  no  other  evidence  of  indigestion  is  present; 
later  the  vomited  material  contains  mucus  which  may  be  tinged  with 
blood  or  bile.  The  child  becomes  extremely  thirsty,  but  ejects  every 
drop  of  water  swallowed;  consequently,  after  a  few  attempts,  drink- 
ing is  abandoned  and  the  little  one  simply  lies  quietly  on  its  back. 
There  is  occasional  complaint  of  pain  in  the  stomach,  both  before 
and  during  an  attack,  and  constipation  is  usually  present.  The 
temperature,  as  a  rule,  is  normal  or  subnormal.  The  pulse  at  first 
is  slightly  accelerated  and  strong,  but  becomes  weak  when  exhaustion 
sets  in. 

After  two  or  three  days  the  attack  may  suddenly  cease  or,  in  some 
instances,  the  vomiting  gradually  decrease  in  severity  and  frequency 
until  it  stops  altogether,  when  the  child  quickly  regains  strength, 
and  may  be  perfectly  well  for  weeks  or  months  until  another  attack 
supervenes.  As  a  rule,  the  attacks  cease  entirely  at  puberty,  although 
rare  cases  have  been  reported  in  which  cyclic  vomiting  continued  to 
recur  until  adult  life. 

Diagnosis. — Unless  one  can  obtain  a  history  of  preceding  periodical 
attacks,  the  diagnosis  of  cyclic  vomiting  is  difficult,,  and  should  only 
be  made  after  careful  exclusion  of  the  more  common  causes  of  vomit- 
ing, and  in  the  absence  of  any  signs  or  symptoms  of  gastro-intestinal 
derangement.  Among  the  many  causes  of  vomiting  which  must  be 
excluded  are  tuberculous  meningitis,  volvulus,  intussusception,  and 
appendicitis.     Absence  of  fever  is  significant  as  eliminating  inflam- 


266  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

rnatory  lesions  f)f'  the  gastro-intestinal  tract,  and  a  rapid  pulse  and 
good  physical  condition  of  the  child  usually  exclude  tuberculous 
meningitis. 

Prognosis. — ^The  prognosis  of  cyclic  vomiting  is,  on  the  whole,  favor- 
able, since  the  majority  of  children  survive  the  most  severe  attacks, 
and  quickly  regain  their  normal  health  and  vigor  when  the  vomiting 
ceases. 

Treatment. — When  an  attack  of  cyclic  vomiting  comes  on,  the 
child  should  be  put  to  bed,  and  for  twenty-four  hours  nothing  should 
be  given  it  by  mouth  but  a  few  sips  of  water.  It  is  a  good  plan  to  give 
an  enema  as  soon  as  an  approaching  attack  is  suspected,  and  the 
injection  may  be  repeated  once  or  twice  daily  until  vomiting  ceases. 
After  twenty-four  hours  the  very  lightest  nourishment,  preferably 
albumin  water  or  weak  broth,  may  be  allowed  in  small  quantities, 
and,  if  this  is  not  retained,  nutrient  enemata  may  be  resorted  to. 
If  fluids  do  not  excite  vomiting,  soft  food  may  be  given  the  child  on 
the  following  day,  and  full  diet  gradually  resumed. 

For  the  control  of  vomiting,  morphin  and  codein  are  the  most 
efficient  drugs,  but  the  dosage  should  be  carefully  graduated  accord- 
ing to  the  age,  because  of  the  idiosyncrasy  of  children  to  opiates.  In 
view  of  the  fact  that  acidosis  is  frequently  responsible  for  cyclic  vomit- 
ing, an  alkali,  such  as  sodium  bicarbonate,  which  may  be  given  in 
10-  to  20-grain  doses  every  hour,  will  often  bring  about  excellent 
results.  Older  children  may  be  given  larger  doses;  and,  if  the  infant 
or  child  does  not  retain  this  drug  when  given  by  mouth,  twice  the 
dose  should  be  administered  by  rectum.  In  the  course  of  a  day  the 
infant  should  receive  1  dram,  and  the  child  2  drams,  if  the  drug  is 
to  have  any  appreciable  effect. 

The  diet  of  these  children  should  be  very  much  restricted  in  its 
carbohydrate  content  because  of  the  acidosis  and  evident  relation 
between  cyclic  vomiting  and  inefficient  carbohydrate  metabolism. 
Salt  water  bathing  and  massage  are  valuable  adjuncts  to  the  treat- 
ment. In  addition  to  the  specific  measures  outlined  above,  these 
children  often  improve  if  given  the  advantage  of  hygienic  surround- 
ings. As  a  prophylactic  measure  against  future  attacks,  the  bowels 
should  be  so  regulated  as  to  make  sure  of  a  daily  movement. 

GASTRALGIA. 

Gastralgia  is  neuralgic  pain  in  the  abdomen,  usually  located  in 
or  about  the  stomach,  and  due  to  irritation  of  the  sensory  gastric 
nerves.  It  is  quite  common  in  infancy.  Little  or  nothing  is  definitely 
known  as  to  its  etiology,  since  it  occurs  regardless  of  whether  the 
stomach  is  empty  or  full;  therefore  it  is  apparenth'  reflex,  and  due 
to  external,  constitutional,  or  visceral  disturbances. 

Symptoms. — ^The  attacks  usually  come  on  suddenly,  and  may  last 
for  a  few  minutes  or  several  hours,  during  which  time  the  patient 
may  be  prostrated.     Vomiting  is  rare.     The  epigastrium  shows  no 


INDIGESTION  267 

sign  of  teiulerness  upon  pulpatioii,  and  rcco\('r>-  is  proni])t  when  the 
pain  ceases. 

Diagnosis. — The  diagnosis  of  gastralgia  should  always  be  held  in 
reserve  until  every  other  possible  cause  of  abdominal  pain  is  excluded. 
This  involves  careful  and  thorough  history  taking,  as  well  as  physical 
examination,  especially  in  very  young  children  who  are  unable  to 
locate  the  pain. 

Treatment. — ^The  child  should  be  put  to  bed,  and  a  hot  application, 
such  as  a  mustard  plaster,  hot  water  bag,  or  a  turpentine  stupe,  may 
be  placed  over  the  epigastrium.  Internahy,  hot  water  with  5  to  10 
drops  of  spirits  of  chloroform,  or  10  to  30  drops  of  brandy  or  gin, 
or  a  teaspoonful  of  peppermint  water,  will  often  give  relief.  If  these 
measures  fail  and  the  condition  grows  worse,  the  child  should  be  closely 
watched  for  signs  or  symptoms  of  more  serious  nature. 

Children  who  suffer  from  repeated  attacks  of  gastralgia  need  a 
carefully  regulated  diet,  and  their  bow^els  should  be  moved  at  least 
once  daily.  The  administration  of  Fowder's  solution,  1  drop  doses 
three  times  a  day,  to  a  child  of  five  years,  and  smaller  doses  to  younger 
children,  gradually  increased  to  the  point  of  tolerance,  is  of  great 
value  in  the  prevention  of  subsequent  attacks,  if  kept  up  throughout 
the  interim.  Tincture  of  nux  vomica,  in  2  drop  doses,  may  also  be 
given,  either  alone  or  in  combination  with  arsenic.  These  children 
should  spend  most  of  their  time  in  the  open  air,  but  overexercise 
must  be  guarded  against,  as  fatigue  is  very  harmful. 

INDIGESTION. 

Fat  Indigestion. — Indigestion  during  infancy,  both  in  the  nursling 
and  m  the  bottle-fed  baby,  is  quite  often  to  be  attributed  to  an  excess 
of  fat;  and  since  in  infancy  the  digestion  of  fat  is  accomplished  for 
the  most  part  in  the  small  intestines,  the  symptoms  of  fat  indigestion 
are  chiefly  referable  to  the  intestines,  and  are  to  be  discerned  in  the 
stools.  Vomiting  is  a  common  symptom  in  these  cases.  In  the 
infant's  stomach  a  fat-splitting  ferment  is  present. 

Etiology. — Indigestion  caused  by  an  excess  of  fat  in  the  ingested 
milk  is  far  less  common  in  the  breast-fed  infant  than  in  the  bottle-fed 
baby;  but  the  nursling  may  also  suffer  from  fat  indigestion  because 
of  an  idiosyncrasy  to  fats.    This,  however,  is  quite  rare. 

In  another  case  the  mother,  believing  that  her  milk  is  poor,  may 
give  her  child  a  teaspoonful  or  tw^o  of  cream  with  each  nursing  under 
the  erroneous  impression  that  the  more  fat  the  baby  takes  the  fatter 
it  will  grow.  As  a  result,  the  child  ingests  an  amount  of  fat  far  in 
excess  of  its  actual  need  or  digestive  capability.  In  artificially  fed 
infants  fat  indigestion  is  quite  common  because  of  the  prevailing 
tendency  among  physicians,  when  making  up  formulas,  to  prescribe 
an  excessive  percentage  of  fat  rather  than  one  too  low. 

Symptoms. — The  breast-fed  infant  rarely  suffers  much  from  an 
excess  of  fat,  even  though  the  mother's  milk  be  too  rich;  for,  if  exces- 


268  DISEASES  OF   THE  GASTRO-INTESTIKAL  TRACT 

sively  fat,  regurgitation  follows  each  feeding,  and  the  child  usually 
soon  becomes  able  to  digest  a  slightly  higher  percentage  than  normal. 
In  addition  to  regurgitation  the  baby  loses  its  appetite,  this  also 
being  a  conservative  measure  on  the  part  of  Nature  to  limit  the  quan- 
tity of  fats  ingested.  The  bowels  become  loose,  the  stools  contain 
fat  curds  and  fat-free  globules,  and  there  is  usually  much  flatulence 
and  colic. 

Continued  disturbance  in  the  digestion  of  fats  results,  first,  in  a 
failure  to  gain  weight,  and,  subsequently,  in  loss  of  weight;  but,  as 
a  rule,  in  the  nursling  fat  indigestion  is  not  attended  by  any  serious 
impairment  of  health.  The  bottle-fed  baby,  however,  usually  fares 
worse.  The  symptoms  of  fat  indigestion  already  enumerated  become 
exaggerated,  and,  in  addition,  high  fever  generally  accompanies  the 
acute  digestive  disturbance.  The  stools  may  be  either  very  loose, 
green  in  color,  and  composed  of  curds  and  mucus;  or  very  watery 
and  acid  in  reaction;  or  dry  and  well  formed,  and  of  a  whitish  or 
grayish  color — the  "soap  stool,"  formed  by  a  combination  of  fat  and 
an  alkaline  salt.  In  some  instances  the  loss  of  alkaline  salts  in  the 
stools  may  be  so  great  as  to  cause  a  relative  acidosis  with  the 
characteristic  symptoms  of  acid  intoxication,  such  as  increase  in 
the  respiratory  rate,  stupor,  or  extreme  restlessness. 

If  acute  fat  indigestion  is  not  relieved  within  a  short  time  it  soon 
becomes  chronic,  and,  not  only  is  the  digestive  power  of  the  infant 
impaired,  but  other  disturbances  of  metabolism  arise  and  result  in 
rachitis,  infantile  atrophy,  or  "marasmus."  Loss  of  weight  is  progres- 
sive and  continuous,  and  even  though  the  child  be  given  excellent 
care  recovery  is  at  best  a  slow  and  tedious  process. 

Treatment. — When  indigestion  is  due  to  an  excess  of  fat  in  the 
mother's  milk,  the  amount  taken  at  each  feeding  should  be  reduced 
by  shortening  the  nursing  period.  We  can  also  lower  the  fat  content 
of  the  breast  milk  by  giving  the  baby  a  small  quantity  of  water  imme- 
diately before  it  nurses.  If  the  infant  is  losing  weight  because  of 
insufficient  food,  the  interval  between  feedings  may  be  shortened  so 
that  the  child  will  get  the  same  amount  of  nourishment  at  each  feed- 
ing as  it  previously  received,  but  be  fed  more  often  in  the  twenty-four 
hours  and,  consequently,  receive  a  larger  amoinit  of  food. 

The  percentage  of  fat  in  the  mother's  milk  may  also  be  to  some 
extent  decreased  by  reducing  her  diet,  especially  with  regard  to  pro- 
tein, and  by  increasing  the  amount  of  exercise  she  takes.  Since  the 
milk  obtained  when  the  breast  is  almost  empty  is  richest  in  fat,  it 
is  advisable  to  let  the  infant  nurse  only  half  the  contents  of  each 
breast  rather  than  to  take  the  full  feeding  from  one  breast.  If  these 
measures  fail  to  adapt  the  breast  milk  to  the  infant's  digestive  powers, 
it  is  sometimes  necessary  to  procure  a  wet  nurse. 

In  these  cases  w^here  the  mother  has  been  in  the  habit  of  giving 
the  child  a  teaspoonful  or  so  of  cream  in  addition  to  the  breast  milk, 
it  is  a  simple  matter  to  relieve  fat  indigestion;  for  on  discontinuing 
the  practice  the  condition  soon  passes  away.     Intolerance  to  fat  is 


INDIGESTION  209 

fortunately  very  rare;  but,  when  encountered,  the  sole  resource  is 
skimmed  milk,  and  it  is  only  with  greatest  difficulty  that  the  caloric 
requirements  of  the  infant  can  be  supplied. 

When  fat  indigestion  arises  in  artificially  fed  infants,  a  fat-free  diet 
should  be  instituted,  and,  for  two  or  three  days  at  least,  no  fats  what- 
ever be  allowed.  After  this  time  a  small  amount  may  be  added  to 
each  feeding,  and  the  percentage  of  fat  gradually  increased  from  time 
to  time,  according  to  the  degree  of  tolerance  established. 

An  indication  as  to  the  proportion  of  fat  being  digested  is  readily 
furnished  by  observation  of  the  stools,  which  should  be  carefully 
examined  whenever  the  amount  of  fat  is  to  be  increased.  Any  evidence 
of  excessive  fat  ingestion  calls  for  immediate  reduction  in  the  percent- 
age of  fat,  as  intolerance  is  very  quickly  precipitated;  and  it  is  much 
safer  to  increase  the  amount  of  protein  and  carbohydrates  if  the 
formula  be  too  weak,  although  it  is  difficult  to  furnish  in  this  way 
an  equal  number  of  calories  without  setting  up  digestive  disturbance. 
When  there  is  an  idiosyncrasy  to  the  fat  of  cow's  milk,  a  wet-nurse 
should  be  secured,  since,  as  a  general  rule,  in  these  cases  human  milk 
is  well  borne,  whereas  it  is  impossible  to  change  the  character  of  the 
fat  in  cow's  milk  or  to  modify  it  in  any  way. 

In  the  summer  months  many  cases  of  fat  indigestion  may  be  pre- 
vented by  reducing  the  percentage  of  fat  in  the  feeding  mixtures,  as 
even  healthy  infants  show  a  greater  intolerance  to  fat  at  this  season 
of  the  year.  In  the  treatment  of  fat  indigestion  it  is  usually  wise  to 
give  an  initial  purge,  castor  oil  in  full  dosage  being  most  effective. 
If  the  case  be  very  severe,  the  stomach  should  be  given  a  rest  by 
withholding  all  food  for  from  twelve  to  twenty-four  hours  after 
purgation. 

Carbohydrate  Indigestion. — Sugar  indigestion  in  the  breast-fed 
infant  is  quite  rare,  but  is  readily  induced  in  artificially  fed  babies, 
either  because  they  have  ingested  an  excessive  amount  of  carbohy- 
drates or  have  taken  an  unsuitable  form  of  starch  or  sugar. 

Etiology. — ^The  amount  of  sugar  in  human  milk  seldom  varies  more 
than  1  or  2  per  cent.  As  a  rule,  this  excess  is  readily  digested  by 
the  healthy  infant.  Only  in  exceptional  cases  do  digestive  disturb- 
ances arise,  and  they  are  usually  very  mild,  being  marked  by  vomit- 
ing, diarrhea,  eructations  of  gas,  and  more  or  less  colic.  The  stools 
are  thin,  green  in  color,  acid  in  reaction,  and  they  frequently  irritate 
and  excoriate  the  buttocks.  When  carbohydrates  are  given  in  addi- 
tion to  the  breast  milk  for  their  laxative  effect,  or  mixed  feeding  is 
resorted  to,  and  an  excess  thus  received,  the  symptoms  are  more 
severe.  In  artificially  fed  babies  sugar  indigestion  can  most  fre- 
quently be  attributed  to  the  substitution  of  cane  sugar  for  lactose 
or  to  the  too  liberal  use  of  sugar  of  milk.  In  rare  instances  there  is 
a  marked  intolerance  to  milk  sugar  in  even  the  smallest  quantities, 
and  a  more  suitable  carbohydrate  must  be  substituted;  but,  as  a 
rule,  sugar  of  milk  is  very  well  borne  by  artificially  fed  infants  if  the 
feeding  mixture  does  not  contain  more  than  6  or  7  per  cent. 


270  DISEASES  OF   THE   GASTRO-INTESTINAL   TRACT 

Symptoms. — Two  forms  of  carbohydrate  indigestion  are  met  with — 
the  acute  and  the  chronic — and  the  symptoms  vary  according  to  the 
particular  form  of  starch  or  sugar  which  causes  the  disturbance. 
In  all  cases  of  this  nature  diarrhea  is  the  most  prominent  symptom, 
the  stools  being  very  loose,  watery,  and  at  times  frothy.  They  are 
grass-green  in  color,  acid  in  reaction,  and  frequently  contain  mucus. 
Colic  is  severe  owing  to  excessive  fermentation  and  flatulence,  the 
latter  being  demonstrated  by  frequent  eructations  of  gas  whicth 
usually  afford  relief.  The  buttocks  are  irritated  and  excoriated  by 
the  highly  acid  stools,  while  the  excessive  ingestion  of  sugar  causes 
an  eczematous  condition  of  the  face,  and  of  the  scalp  as  well.  The 
vomiting  in  sugar  indigestion  is  not  severe,  and  the  vomitus  has  no 
special  characteristics,  although  it  is  usually  highly  acid  in  reaction. 

In  acute  cases  there  is  often  a  sharp  rise  of  temperature  which  is  of 
short  duration,  and  loss  of  weight  may  be  quite  rapid.  Associated 
with  this  high  fever  and  rapid  loss  in  weight,  there  may  be  decided 
toxemia  with  dulness  or  even  decided  stupor.  In  chronic  cases,  how- 
ever, there  is  no  fever  and  very- little,  if  any,  wasting,  for  the  assimila- 
tion of  large  quantities  of  sugar  causes  an  increase  in  body  weight. 
Carbohydrate  intoxication  may  occur  in  acute  and  severe  cases,  and 
is  then  usually  attended  by  marked  disturbance  of  the  nervous  system 
and  prostration. 

Cane  sugar  when  given  in  excess  produces  the  same  symptoms  as 
sugar  of  milk,  but  is  less  irritating  to  the  intestinal  mucosa.  Starch 
ingested  in  excess  usually  causes  chronic  indigestion,  which  results 
in  disturbances  of  nutrition  rather  than  digestion.  Pure  maltose  is 
never  used  in  infant  feeding;  but  preparations  of  dextrin-maltose 
are  sometimes  employed,  and  if  given  too  freely  produce  much  the 
same  symptoms  as  those  caused  by  too  much  milk  sugar  except  that 
there  is  more  fermentation,  and  colic  and  flatulence  are  more  distress- 
ing. The  stools,  too,  are  dissimilar,  being  usually  of  a  dark  brown 
color.  As  a  rule  infants  suffering  from  carbohydrate  indigestion 
do  not  apparently  lose  in  weight  and  may  even  seem  to  gain;  but 
they  are  pale  and  anemic,  and  if  closely  scrutinized  their  muscle  tissue 
is  found  to  be  loose  and  flabby  so  that,  in  reality,  they  are  in  poor 
physical  condition  and  aie  less  able  than  normal  children  to  combat 
a  severe  illness,  or  to  endure  the  prolonged  strain  often  associated 
with  an  intercurrent  infection. 

Prognosis. — In  acute  forms  of  carbohydrate  indigestion  the  infant 
may  be  quite  ill,  but  the  prognosis  is  somewhat  more  favorable  when 
the  disturbance  is  due  to  dextrin-maltose  or  starchy  preparations 
than  when  caused  by  an  excess  of  some  other  form  of  carbohydrate. 
Chronic  cases  usually  recover,  but  improvement  is  apt  to  be  slow, 
and  not  a  few  of  these  infants  succumb  to  some  acute  intercurrent 
infection. 

Treatment. — An  excess  of  lactose  in  the  mother's  milk  is  usually 
ascribed  to  a  too  generous  diet — too  rich,  not  only  in  carbohydrates, 
but  in  other  food  elements  as  well.    Therefore,  when  sugar  indigestion 


INDIGESTION  271 

appears  in  a  suckling,  the  diet  of  the  mother  should  be  cut  down,  and 
other  steps  taken  to  render  her  milk  less  rich.  When  sugar  of  milk 
is  the  causative  factor  in  artificially  fed  infants,  the  amount  ingested 
should  be  restricted  as  far  as  possible,  and  the  percentage  of  fat  also 
decreased.  In  these  cases  fats  act  as  an  hritant  to  the  intestinal 
mucosa,  and  consequently  are  not  well  borne  in  full  quantities.  If 
possible,  milk  sugar  should  be  absolutely  withheld  for  a  few  days, 
as  lactic  acid  fermentation  in  the  intestine  will  persist  if  even  a  small 
quantity  is  given. 

Since  mother's  milk  contains  7  per  cent,  of  lactose,  and  cow's  milk 
about  4  per  cent.,  the  elimination  of  sugar  of  milk  from  a  mixture 
without  a  dangerous  reduction  in  its  caloric  value  is  not  an  easy  task. 
Protein  is  well  borne,  however,  and  these  infants  show  a  tolerance 
to  small  quantities  of  starch,  therefore  by  giving  a  mixture  of  skimmed 
milk  with  a  cereal  diluent,  the  caloric  needs  of  the  infant  are  fairly 
well  supplied,  and  at  the  same  time  but  a  low  percentage  of  fats 
and  carbohydrates  is  being  ingested.  After  a  few  days  it  is  usually 
possible  to  add  dextrin-maltose  to  the  mixture,  and  then  gradually  to 
return  to  milk  sugar.  Cream  whey  mixtures  are  contraindicated 
because  of  the  relatively  high  percentage  of  milk  sugar  in  whey,  but 
Eiweissmilch  or,  as  it  is  often  called,  albumin  milk,  is  usually  well 
borne. 

When  an  excess  of  dextrin-maltose  has  set  up  indigestion,  the  treat- 
ment is  practically  the  same  as  in  acute  carbohydrate  indigestion 
from  an  excess  of  lactose;  but,  after  dextrin-maltose  has  been  omitted 
from  the  feedings  for  a  few  days,  sugar  of  milk  should  be  substituted. 
Indigestion  due  to  an  excess  of  starch  is  usually  chronic,  and  the  per- 
sistent gastro-intestinal  derangement  so  weakens  the  digestive  powers 
of  the  infant  that,  in  addition  to  withdrawing  starch  from  the  food, 
fats  and  protein  also  must  be  considerably  reduced,  or,  better  still, 
if  possible,  mother's  milk  be  given  instead  of  a  feeding  mixture.  If 
a  wet-nurse  cannot  be  procured,  a  cream  whey  mixture,  or  a  rather 
weak  formula  containing  not  more  than  2  per  cent,  of  fat,  4  per  cent, 
of  sugar,  and  1  per  cent,  of  protein  should  be  given,  and  these  propor- 
tions gradually  increased.  At  the  onset  it  is  always  well  to  give  the 
gastro-intestinal  tract  a  thorough  cleansing  by  a  full  dose  of  castor 
oil,  and  in  severe  cases  the  stomach  should  be  given  complete  rest  by 
withholding  everything  but  water  for  twelve  to  twenty-four  hours 
following  the  purge. 

Protein  Indigestion. — Food  injuries  in  the  breast-fed  infant  are  more 
often  due  to  an  excess  of  protein  in  the  mother's  milk  than  to  an 
excess  of  either  fat  or  sugar.  The  artificially  fed  baby  suffers  from 
protein  indigestion  only  when  cow's  milk  forms  a  part  of  the  feeding 
mixture;  for  even  though  it  is  able  to  digest  a  higher  percentage  of 
protein  than  is  found  in  mother's  milk,  the  protein  in  cow's  milk  con- 
tains so  much  casein  that  an  infant  fed  on  a  cow's  milk  mixture  can 
easily  receive  an  excessive  amount  of  casein,  and  indigestion  be  the 
result. 


272  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

Etiology. — A  high  percentage  of  protein  in  mother's  milk  is  usually 
the  result  of  an  excessive  protein  diet  on  her  part,  and  either  an  excess 
or  a  lack  of  exercise.  The  milk  of  neurotic  mothers  and  those  who 
have  been  subjected  to  nervous  shock,  such  as  grief,  worry,  or  fright, 
is  apt  to  contain  a  higher  percentage  of  protein  than  normal,  and 
during  the  first  ten  days  of  lactation,  before  the  equilibrium  of  milk 
secretion  is  definitely  established,  the  milk  contains  more  protein 
than  it  does  later.  The  quantity  of  protein  in  human  milk  may  be 
as  high  as  4  per  cent.;  but  the  excess  is  rarely  more  than  2  per  cent, 
above  normal.  In  artificially  fed  infants  protein  indigestion  is  usually 
induced  by  an  excess  of  casein,  and  is  but  rarely  caused  by  a  high 
percentage  of  whey.  Exceptional  cases  have  been  recorded  of  infants 
who  have  shown  evidence  of  anaphylaxis  to  the  protein  of  cow's  milk, 
and  were  unable  to  digest  the  smallest  quantities,  owing  to  sensitiza- 
tion of  the  system  from  absorption  of  the  protein  of  cow's  milk  during 
the  first  few  days  after  birth,  when  the  intestines  were  in  an  abnormal 
condition. 

Symptoin.s. — Habitual  colic  is  one  of  the  most  characteristic  symp- 
toms of  excessive  protein  ingestion  during  early  infancy,  whether  in 
the  breast-fed  or  bottle-fed  infant.  In  the  nursling  the  other  symp- 
toms of  protein  indigestion  are  slight.  Vomiting  is  rare,  but  there  is 
usually  considerable  flatulence.  The  stools  are  loose,  watery,  and  of 
a  brown  color;  they  contain  mucus,  and  quite  frequently  fat  curds 
due  to  an  accompanying  inability  to  digest  fats.  The  temperature 
is  not  elevated  except  in  extremely  acute  cases,  when  a  sharp  rise  may 
occur.  Breast-fed  infants,  as  a  rule,  show  no  marked  disturbance  of 
nutrition  as  a  result  of  protein  excess,  and  lose  very  little  weight. 
In  infants  who  are  being  fed  an  excessive  amount  of  whey  protein 
digestive  disorders  can  usually  be  attributed  to  an  excess  of  sugar 
and  salts  in  the  whey,  since  whey  itself  rarely  gives  rise  to  indi- 
gestion. 

Casein,  on  the  other  hand,  owing  to  the  large,  hard  curds  it  forms, 
may  derange  the  digestion.  The  symptoms  produced  by  an  excess 
of  casein  may  be  quite  severe.  Vomiting  is  not  unusual,  the  vomitus 
containing  large  curds  which  are  hard  and  tough  in  contrast  to  the 
soft  curds  found  in  fat  indigestion.  These  curds  may  also  be  seen 
in  the  stools  as  white,  gray,  or  green  particles,  frequently  covered 
with  a  coating  of  mucus  when  passed.  As  a  rule,  diarrhea  accom- 
panies this  form  of  the  affection,  but  constipation  is  not  uncommon, 
and  in  some  instances  the  stools  are  normal  in  every  respect  except 
for  the  presence  of  curds.  Colic  and  flatulence  are  usually  severe, 
and  evacuations  of  the  bowels  may  be  accompanied  by  much  pain. 
Ordinarily  there  is  little  or  no  elevation  of  temperature. 

Prognosis. — The  prognosis  in  protein  indigestion  is  much  more 
favoraole  than  when  the  disturbance  of  digestion  is  due  to  an  excess 
of  fat  or  carbohydrates.  Breast-fed  infants,  as  a  rule,  rapidly  recover 
when  the  excess  of  protein  is  removed  from  the  mother's  milk;  and, 
since  it  is  a  simple  matter  to  reduce  the  percentage  of  protein  in 


INDIGESTION  -  273 

feeding  mixtures,  artificially  fed  babies  rarely  suffer  any  serious  or 
lasting  ill  effects. 

Treatment. — When  the  breast  milk  is  found  to  contain  an  excess 
of  protein,  the  cause  of  this  excess  should  be  ascertained  and  counter- 
acted as  quickly  as  possible.  If  the  diet  be  too  rich  it  should  be  cut 
down;  if  the  mother  is  taking  too  much  exercise  she  must  stop  short 
of  fatigue  in  the  future;  and  if  her  life  has  been  too  sedentary  she  must 
be  induced  to  take  a  moderate  amount  of  exercise.  Grief,  worry, 
anxiety,  and  other  nervous  states  should  always  be  guarded  against 
during  lactation.  In  the  bottle-fed  baby  protein  indigestion  can 
usually  be  relieved  by  reducing  the  percentage  of  casein  in  the  feed- 
ing mixture,  and  substituting  whey  protein  in  order  to  satisfy  the 
protein  needs  of  the  infant. 

The  formation  of  large  casein  curds  may  also  be  prevented  by  pep- 
tonizing the  milk  or  by  the  addition  of  alkalies,  such  as  lime  water, 
or  solution  of  sodium  bicarbonate,  or  cereal  diluents,  such  as  barley- 
water  or  rice-water.  Sodium  citrate  added  to  milk  also  prevents 
the  precipitation  of  casein  curds,  but  has  the  disadvantage  of  being 
constipating.  When  protein  indigestion  causes  watery  brown  stools, 
it  is  advisable  to  cut  out  the  protein  for  a  day  or  two,  substituting 
carbohydrates  in  its  place,  and  then  restore  the  protein  to  the 
mixture.  In  addition  to  dietetic  regulation  an  initial  purge  of 
castor  oil  should  be  given  to  sweep  all  of  the  large  casein  curds 
out  of  the  gastro-intestinal  tract. 

Feces. — The  first  stools  after  birth  are  of  a  dark  and  almost  black 
color,  and  they  remain  so  until  the  infant  takes  milk  from  the  breast, 
after  which  they  become  yellow,  are  of  a  pasty  consistency,  and  acid 
in  reaction.  If  the  infant  is  fed  by  the  bottle  the  stools  are  lighter 
in  color  and  larger  in  bulk  than  those  of  the  breast-fed  infant,  but, 
as  a  rule,  are  fewer  in  number,  the  normal  nursling  having  two  to  five 
stools  a  day.  Curds  found  in  the  infant  stool  may  be  composed  either 
of  fat  or  protein  (casein),  the  former  being  soft,  and  soluble  in  ether, 
whereas  casein  curds  are  hard,  tough,  usually  larger  than  fat  curds, 
and  insoluble  in  ether.  Green  stools  often  cause  the  mother  great 
concern;  but,  if  the  bowel  discharges  are  otherwise  normal,  this 
change  is  of  no  significance,  being  due  to  the  conversion  of  bilirubin 
into  biliverdin.  White  and  gray  stools  indicate  the  presence  of  fats 
in  the  form  of  soap  and  the  absence  of  bile.  Black  stools  are  usually 
caused  by  the  ingestion  of  drugs,  such  as  iron,  bismuth  subnitrate  or 
charcoal;  but,  in  rare  instances,  the  presence  of  blood  from  the  intes- 
tinal tract  gives  the  discharges  a  black,  tarry  color.  If  bright  scarlet 
blood  appears  in  the  stool,  its  origin  is  an  anal  fissure  or  rectal  polyp. 

Pus  in  the  discharges  indicates  some  severe  inflammation  of  the 
intestines;  and,  while  a  small  quantity  of  mucus  may  be  found  in 
the  normal  stool  with  the  aid  of  a  microscope,  a  considerable  amount 
is  abnormal  and  signifies  intestinal  inflammation.  There  is  only  a 
faint  odor  to  the  stools  of  breast-fed  infants,  while  in  those  of  the 
bottle-fed  baby  it  may  be  quite  pronounced,  and  y^aries  according 
18 


274  DISEASES  OF   THE  GASTRO-INTESriXAL   TRACT 

to  the  diet.  The  stools  in  fat  indigestion  are  loose  and  contain  fat 
curds  and  fat  in  the  form  of  soap.  If  the  mfant  receives  too  little 
of  fats  the  stools  become  dry  and  hard.  Casein  curds  are  characteristic 
of  protein  indigestion,  and  the  stools  are  usually  increased  in  number, 
alkaline  in  reaction,  with  a  decidedly  fecal  odor.  Thin,  watery, 
highly  acid  stools,  which  u'ritate  the  buttocks  and  genitalia,  are 
characteristic  of  sugar  indigestion.  At  the  present  time  the  bacterio- 
logical examination  of  infants'  stools  is  of  little  clinical  value,  owing 
to  our  limited  knowledge  of  the  relation  of  bacteria  to  digestive  dis- 
turbance and  inflammation  of  the  intestines. 

Acute  Gastric  Indigestion. — Acute  gastric  indigestion  is  one  of  the 
most  common  affections  of  infancy  and  childhood. 

Etiology. — Improper  feeding,  whether  irregularity  of  the  feeding 
periods  or  an  excessive  amount  of  food,  is  most  frequently  the  cause 
of  gastric  indigestion  in  infancy;  but  a  change  of  diet,  if  too  radical, 
will  often  bring  on  a  severe  attack  of  indigestion,  while  occasionally 
a  diet,  which  up  to  a  certain  period  has  been  perfectly  suitable,  will 
overtax  the  stomach  because  an  existing  illness  has  lowered  the  power 
of  digestion. 

Ai'tificially  fed  infants  fm-nish  the  majority  of  cases,  for  rarely  is 
there  change  enough  in  breast  milk,  from  nervous  excitement  or  any 
other  cause  in  the  mother,  to  make  it  indigestible;  but  a  protracted 
spell  of  hot  weather,  or  the  substitution  of  a  prepared  food  or  cow's 
milk  for  one  nmsing  period,  will  often  produce  a  severe  attack  of 
gastric  indigestion  in  an  otherwise  healthy  breast-fed  infant.  In 
artificially  fed  babies  the  attack  is  brought  on  by  either  the  poor 
quality  of  the  food  given  or  the  strength  of  the  preparation.  Older 
children  suffer  from  acute  gastric  indigestion  because  of  indulgence 
in  pastry,  candies,  unripe  fruits,  and  other  indigestible  articles,  and 
by  eating  continually  between  meals  or  too  hurriedly  at  table.  The 
disease  is  most  prevalent  during  the  summer  months,  and  frequently 
occurs  during  the  period  of  dentition. 

Symptoms. — ^The  principal  symptoms  of  acute  gastric  indigestion 
are  pain  referred  to  the  hypochondrium,  vomiting,  nausea,  headache, 
and  fever.  Preceding  these  acute  symptoms  there  is  usually  a  period 
of  malaise  during  which  the  child  is  tired,  peevish,  and  shows  no  desire 
to  play.  Vomiting  is  accompanied  by  much  retching.  The  vomitus 
is  som*,  and  composed  of  undigested  food.  The  stomach  is  generally 
somewhat  distended.  In  severe  cases  the  child  may  be  prostrated. 
The  temperature  may  rise  to  104°  F.  or  above.  Convulsions  some- 
times occm*.  The  pulse  becomes  weak  and  rapid.  There  may  be  an 
occasional  chill.  The  breath  is  always  foul,  the  tongue  thickly  coated. 
An  attack  such  as  this  is  usually  preceded  by  constipation,  but  may 
be  followed  by  diarrhea.  For  a  few  days  afterward  the  stomach  is 
very  sensitive,  and  unless  extreme  care  is  exercised  nausea  and  vomit- 
ing may  again  occur. 

Diagnosis. — ^The  diagnosis  of  acute  gastric  indigestion  is  usually' 
a  simple  matter  because  Of  its  frequency  in  childhood;  but  one  should 


ACUTE  GASTRITIS  275 

always  remember  that  the  gastric  disturbance  may  be  merely  a 
symptom  of  one  of  the  acute  infectious  diseases. 

Prognosis. — Recovery,  as  a  rule,  promptly  follows  the  remo^'al 
of  the  cause,  and  rarely  does  a  case  terminate  fatally  if  properly 
treated  at  the  onset.  Occasionally  a  convulsion  will  occur  which,  in 
a  very  weak  infant  or  child,  may  prove  fatal. 

Treatment. — In  every  case  the  stomach  should  be  emptied  as  quickly 
as  possible  with  the  aid  of  a  stomach-tube  or  by  the  administration 
of  an  emetic.  Stomach  w^ashing  is  accomplished  in  infants  by  passing 
a  small  catheter  (No.  16  American)  into  the  baby's  stomach  wdiile 
the  child  is  held  in  an  upright  position,  after  which  it  may  be  laid  on 
the  nurse's  lap  on  its  side.  A  glass  connecting  rod  with  rubber  tubing 
and  a  funnel  at  the  distal  end  is  attached  to  the  catheter,  and  warm 
water  or  salt  solution  poured  into  the  funnel,  and  subsequently 
siphoned  off.  This  is  done  repeatedly  until  the  water  returned  from 
the  stomach  is  perfectly  clear.  In  older  children  it  is  so  difficult  to 
pass  a  stomach-tube  that  this  procedure  is  not  often  attempted; 
but  they  should  be  compelled  to  drink  glass  after  glass  of  warm  water 
and  to  take  one  or  two  drams  of  the  syrup  of  ipecac. 

Once  the  stomach  is  emptied,  nothing  should  be  taken  by  mouth 
for  some  hours  (twelve  to  tw^enty-four)  with  the  exception  of  a 
little  water.  Calomel  is,  perhaps,  the  best  drug  we  can  use,  and  this 
may  be  given  in  grain  doses,  corresponding  to  the  age  of  the  child  up 
to  five  years.  When  nausea  disappears  albumen-water,  barle.y -water, 
or  whe}'  may  be  given  cautiously  in  small  quantities  for  twenty-four 
hours,  after  which  the  breast-fed  infant  may  be  put  to  the  breast  for 
a  nursing  period  of  not  more  than  five  minutes  every  three  hours 
for  the  following  day  or  tw^o,  gradually  increasing  the  length  of  this 
period  until  the  normal  amount  of  food  is  being  taken. 

The  somewhat  older  infant  may  be  given  weak  broths  on  the  second 
day,  and  gruels  or  light  semisolids  following  this,  according  to  the 
improvement  noted.  Constipation  is  usually  relieved  by  the  calomel 
given;  but,  should  it  persist,  a  tablespoonful  of  milk  of  magnesia,  or  a 
half-glass  of  magnesium  citrate,  may  be  given  a  child  of  three  years, 
or  a  soapsuds  enema  or  glycerin  suppository  may  be  resorted  to. 


ACUTE    GASTRITIS. 

Acute  gastritis  is  an  acute  inflammatory  condition  of  the  stomach 
which  rarely  occurs  primarily,  but  is  seen  frequently  during  childhood 
accompanying  that  common  disease,  gastro-enteritis.  The  line  of 
demarcation  between  severe  acute  gastric  indigestion  and  acute  gas- 
tritis is  very  obscure;  but  in  acute  gastritis  we  assume  that  there  are 
lesions  of  the  stomach,  however  slight,  and  we  also  recognize  five 
types  of  this  affection;  i.  e.,  catarrhal,  membranous,  toxic,  ulcerative, 
and  suppurative.  All  but  the  catarrhal  form,  however,  are  so  rare 
that  they  need  only  to  be  mentioned  as  definite  clinical  entities. 


27G  DISEASES  OF   THE  GASTRO-I XTESTI XAL   TRACT 

Etiology. — The  most  frequent  causes  of  acute  gastritis  are  improper 
food,  too  frequent  or  too  liasty  eating,  or  any  of  the  other  factors 
active  in  the  causation  of  acute  gastric  or  gastro-intestinal  indiges- 
tion. It  is  often  observed  during  the  course  of  the  acute  infectious 
diseases,  and  occurs  secondarily  in  many  inflammatory  states  of  the 
intestinal  tract.  The  most  severe  form  of  acute  gastritis  is  that 
which  results  from  the  ingestion  of  strong  acids  or  alkalies. 

Pathology. — In  catarrhal  gastritis  the  gross  changes  are  not  marked, 
but  the  gastric  mucosa  in  certain  areas  is  reddened  and  swollen, 
while  the  stomach  is  either  contracted  or  dilated,  and  contains  undi- 
gested food  and  great  quantities  of  mucus  which  may  be  blood-stained 
from  slight  hemorrhages.  ^Microscopically,  patches  of  mucosa  are 
seen  to  be  infiltrated  with  round  cells,  and  there  are  numerous  erosions 
of  the  epithelium  with  minute  extravasations  of  blood  scattered  over 
the  mucosa. 

The  gastritis  produced  by  corrosives  or  acids  is  characterized  by 
large  ulcerated  areas  denuded  entirely  of  mucous  membrane,  though 
but  rarely  does  the  ulcer  penetrate  the  stomach  wall.  In  membranous 
gastritis  a  false  membrane  forms  on  the  lining  of  the  stomach,  the 
cause  of  which  is  either  the  diphtheria  or  pseudodiphtheria  bacillus. 
Ulcerative  gastritis  is  merely  an  inflammation  of  the  gastric  mucosa, 
characterized  by  the  formation  of  numerous  small  erosions  or  ulcera- 
tions. If  pus  be  present  in  the  stomach  wall  the  condition  is  known 
as  suppurative  gastritis,  but  this  is  very  rare. 

Symptoms. — At  the  onset  of  the  disease  the  symptoms  of  acute 
catarrhal  gastritis  differ  from  those  of  acute  gastric  indigestion  only 
in  the  degree  of  severity.  Vomiting  is  decidedly  worse,  and  may 
persist  for  several  days  or  even  a  week.  The  vomitus  is  at  first  com- 
posed of  undigested  food,  but  later  consists  of  mucus  tinged  with  bile 
or  even  blood.  There  is  a  sudden  rise  of  temperature  to  104°  or  105° 
F.,  which  is  significant  of  rapid  absorption  of  toxins,  while  pain  may 
be  so  severe  that,  in  addition  to  rigidity  of  the  abdominal  muscles,  the 
muscles  of  the  legs  are  contracted  and  fixed,  drawing  the  thighs  up 
toward  the  abdomen.  The  belly  is  visibly  distended,  and  so  tender 
that  the  child  protests  by  screaming  if  any  attempt  be  made  to 
palpate  it.  The  pulse  is  accelerated,  and  ranges  between  140  and  160, 
the  respiratory  rate  also  being  increased.  Thirst  is  extreme  and  hard 
to  relieve;  the  mouth  is  dry;  the  tongue  heavily  coated;  the  breath 
has  a  fetid  odor. 

In  severe  cases  convulsions  may  occur  at  the  onset  of  the  attack; 
but,  if  vomiting  continues,  exhaustion  sets  in  and  the  child  may  become 
prostrated.  Constipation  usually  precedes  the  attack,  but  many 
times  there  is  diarrhea,  numerous  foul-smelling,  semiformed  stools 
being  passed  daily.  The  urine  throughout  an  attack  of  acute  gastritis 
is  scanty,  high-colored,  acid,  and  concentrated  owing  to  the  loss  of 
body  fluids  through  other  channels. 

Suppurative  gastritis  is  characterized  by  the  same  symptoms, 
although  it  is  usualh'  of  longer  duration. 


ACUTE  GASTRITIS  2/7 

MeiiibraJious  gastritis  can  l)c  diagnosed  only  after  deatli,  since 
the  symptoms  are  not  characteristic,  and  the  affection  is  such  a 
rarity  as  to  afford  no  opportunity  for  its  study. 

The  symptoms  of  ulcerative  gastritis  are  much  the  same  as  in  the 
acute  catarrhal  form,  but  the  former  is  marked  by  more  hemorrhages 
from  the  mucous  membrane  of  the  stomach. 

Acute  gastritis  not  infrequently  extends  into  the  duodenum,  which 
is  indicated  by  the  appearance  of  jaundice,  especially  in  older  children. 

Diagnosis. — Acute  gastritis  is  only  to  be  differentiated  from  acute 
gastric  indigestion  by  the  severity  and  persistence  of  the  symptoms. 
Close  observation  for  several  days  is  also  necessary  before  one  can 
definitely  say  that  the  gastric  disturbance  is  not  merely  the  beginning 
of  one  of  the  acute  infections.  Meningitis  is  often  closely  simulated 
by  acute  gastritis;  but  in  meningitis  the  pulse  rate  is  slow,  while  in 
acute  gastritis  it  is  accelerated,  and  this  differential  point,  together 
with  the  local  signs  and  symptoms  in  acute  gastritis,  should  make 
the  correct  diagnosis  easy.  Pneumonia  is  sometimes  suggested;  but 
careful  examination  of  the  chest  will  fail  to  elicit  any  physical  sign 
of  this  disease;  while  if  typhoid  fever  be  suspected  abdominal  exam- 
ination will  reveal  neither  the  enlarged  spleen  and  liver  nor  the  typical 
rose  spots,  and  a  Widal  test  will  verify  these  negative  findings.  A 
valuable  aid  in  the  diagnosis  of  acute  gastritis  is  an  accurately  taken 
history  in  which  particular  attention  is  directed  to  the  nature  of  the 
child's  diet. 

Course  and  Prognosis. — The  usual  duration  of  an  attack  of  acute 
catarrhal  gastritis  is  fiom  several  days  to  a  w^eek,  after  which  time 
the  infant  or  child  who  has  previously  enjoyed  good  health  will  have 
an  uneventful  recovery.  On  the  contrary,  in  weak,  marasmic  infants 
and  poorlv  nourished,  anemic  children,  acute  gastritis  sometimes 
proves  quickly  fatal  or,  more  often,  shows  a  tendency  to  become 
chronic,  and  the  patient  gradually  so  loses  weight  and  strength  that 
it  easily  succumbs  to  some  slight  infection. 

Treatment. — This  differs  but  little  from  the  treatment  of  acute 
gastric  indigestion.  The  stomach  should  be  emptied  immediately, 
and  as  long  as  vomiting  persists  the  best  way  to  accomplish  this  is 
either  to  wash  the  stomach  out  in  the  way  described  under  the  treat- 
ment of  acute  gastric  indigestion,  or,  if  this  is  impossible,  as  is  usually 
the  case  in  older  children,  emesis  should  be  secured  by  administering 
1  or  2  drams  of  syrup  of  ipecac  and  then  compelling  the  child  to 
drink  glass  after  glass  of  warm  salt  solution. 

Purgation  should  be  produced  if  possible,  and  1  grain  of  calomel 
given  to  infants  in  y ^-grain  tablets  every  half-hour,  or  2  grains  of  calo- 
mel given  in  ^-grain  doses  to  older  children,  if  followed  by  a  purgative 
dose  of  magnesium  sulphate,  is  an  excellent  therapeutic  aid  in  treat- 
ment. Nothing  but  this  medicine  should  be  put  in  the  stomach  for 
from  twenty-four  to  forty-eight  hours.  If  thirst  is  extreme  small 
bits  of  ice  or  sips  of  cold  water  may  be  given  the  child. 

The  symptoms  of  acute  gastritis  rarely  require  special  attention; 


278  DISEASES  OF   THE  GASTRO-INTESTTNAL   TRACT 

but  if  fever  runs  liigh  the  eliild  may  l>e  spoiiged  with  tepid  water,  and 
if  convulsions  appear  it  should  be  put  in  a  warm  bath.  Children  and 
infants  in  poor  physical  condition  occasionally  require  stimulation 
by  means  of  the  hypodermic  administration  of  camphorated  oil, 
1  drop  for  each  year  of  the  child's  age.  Aromatic  spirits  of  ammonia, 
10  to  40  drops,  diluted  w^ith  water,  if  retained  when  given  by  the 
mouth,  is  often  followed  by  marked  stimulation.  If  oral  adminis- 
tration of  drugs  be  impossible,  an  ounce  of  black  coffee  may  be  given 
by  rectum.  If  vomiting  persists,  cerium  oxalate  in  |-grain  doses, 
combined  with  bismuth  subnitrate,  gr.  x,  should  be  administered 
every  three  hours,  this  dosage  being  suitable  for  a  child  of  three  years. 
The  stomach  should  be  washed  out  two  or  three  times  daily. 

After  the  active  symptoms  have  subsided  and  nausea  has  ceased, 
feeding  may  be  very  gradually  resumed.  For  the  first  day  or  so  after 
a  period  of  starvation,  the  breast-fed  infant  may  be  allowed  a  nursing 
period  of  at  first  three  minutes,  and  later  five  minutes,  every  four 
hours,  each  nursing  to  be  preceded  by  the  administration  of  two  or 
three  ounces  of  sweetened  water  to  dilute  the  milk.  If  improvement 
continues,  and  the  baby  seems  unsatisfied,  the  nursing  periods  may 
be  gradually  lengthened  until  the  child  gets  the  normal  quantity  of 
breast  milk  at  each  feeding. 

Artificially  fed  infants  should  be  deprived  of  milk  for  even  a  longer 
period — barley-water,  albumen-water,  rice-water,  or  whey  taking  the 
place  of  the  usual  formula  for  several  days,  or  until  the  stomach  can 
again  retain  food,  when  a  little  milk  may  be  added  to  these  prepara- 
tions, increasing  the  amount  at  each  feeding  until  the  full  quota  is 
being  taken.  If,  while  milk  is  being  given,  any  symptoms  of  gastritis 
appear,  the  milk  should  be  immediately  stopped.  Lime-water  is  an 
excellent  diluent  for  milk  in  such  cases,  and  if  milk  or  cane  sugar  is 
not  borne  well  by  the  stomach,  saccharin  or  glycerin  may  be  added 
to  the  formula  to  make  it  palatable. 

Older  children  should  be  kept  on  gruels  and  broths  for  the  first  day 
or  so  after  it  is  deemed  advisable  to  begin  feeding,  and  if  the  stomach 
continues  to  improve,  junket,  jellies,  stewed  fruits,  and  other  semi- 
solid foods  should  be  given,  gradually  increasing  the  strength  of  the 
nourishment,  until  the  child  is  again  on  full  diet.  Tincture  of  nux 
vomica  is  sometimes  a  great  aid  to  digestion  in  these  children,  and 
may  be  given  in  three  minim  doses  three  times  a  day  combined, 
for  a  child  of  five  years,  with  dilute  hydrochloric  acid  iii  5-minim 
doses. 

In  the  treatment  of  corrosive  gastritis,  much  the  same  procedure 
is  carried  out,  except  that  the  stomach-tube  should  never  be  passed 
because  of  the  danger  of  perforation.  An  antidote  should  be  given 
immediately,  and  emesis  must  be  secured  by  forcing  the  patient  to 
drink  excessive  quantities  of  warm  water  until  vomiting  ensues,  and 
the  water  returns  clear  from  the  stomach.  Morphine  is  required  for 
the  relief  of  pain,  and  when  nourishment  is  craved  nothing  should  be 
given  by  mouth  but  oils  and  milk.    Stimulants  sUch  as  are  prescribed 


ACUTE  GASTRO-ENTERlTL^— SUMMER  DIARRHEA         279 

iiiider  the  treatment  of  acute  catarrhal  gastritis  are  even  more  neces- 
sary, but  in  corrosive  gastritis  are  often  useless,  since,  if  much  of  the 
poison  has  been  swallowed;  no  treatment  available  will  prevent  a 
fatal  termination. 

GASTRODUODENITIS . 

Gastroduodenitis  occurs  commonly  as  a  result  of  the  extension  of 
acute  catarrhal  inflammation  of  the  stomach  into  the  duodenum, 
causing  jaundice  by  involvement  of  the  bile  ducts.  It  is  usually 
most  alarming  to  the  parents,  but  is  not  regarded  as  a  serious  compli- 
cation of  gastritis. 

Symptoms. — ^The  symptoms  of  acute  catarrhal  gastritis  vary  little 
with  involvement  of  the  duodenum.  Jaundice  is  the  most  prominent 
feature.  The  stools  are  clay-colored,  the  bowels  constipated.  The 
urine  is  stained  with  bile.  On  examination  of  the  abdomen,  the  liver 
is  usually  found  to  be  enlarged. 

Treatment. — The  diet  should  be  restricted  to  liquids.  The  infant 
may  be  given  whey,  albumen-water,  or  barley-water  instead  of  milk, 
while  the  older  child  should  take  only  broths  and  diluted  milk  until 
improvement  is  noted.  Cholagogues  are  indicated  in  gastroduodenitis, 
and  there  are  several  which  may  be  used  with  equally  good  results. 
The  phosphate  of  soda  may  be  given  daily  in  from  10-  to  30-grain 
doses  to  either  infant  or  child,  or  podophyllum  may  be  administered 
twice  daily  in  from  yV-  to  j-grain  doses,  according  to  the  age  of  the 
patient.  Under  careful  treatment  the  jaundice  should  disappear  in 
the  course  of  three  to  ten  days. 

ACUTE    GASTRO-ENTERITIS— SUMMER   DIARRHEA— SUMMER 

COMPLAINT. 

Acute  gastro-enteritis  is  the  most  common  form  of  infectious  diar- 
rhea met  with  in  children.  It  may  be  caused  by  either  the  dysentery 
bacillus  of  Shiga  and  Flexner,  the  streptococcus,  the  colon  bacillus, 
the  Bacillus  pyocyaneus,  or  the  gas  bacillus.  The  disease  differs  from 
ordinary  diarrhea  with  fermentation  in  that  the  bacteria  are  found 
in  the  walls  of  the  intestines  where  they  may  produce  lesions,  while 
in  fermentative  indigestion  bacterial  activity  is  confined  to  the  intes- 
tinal contents. 

Etiology. — Acute  gastro-enteritis  has  been  aptly  termed  "summer 
complaint"  because  of  its  prevalence  in  hot  weather,  a  fact  explained 
by  the  lowered  vitality  of  infants  in  hot  weather,  and  by  the  readiness 
with  which  milk  and  other  foods  become  contaminated  and  spoil  at 
this  season. 

Digestion  also  is  inhibited  to  such  a  degree  in  hot  weather  that  a 
feeding  mixture,  which  might  be  perfectly  suited  to  an  infant's  diges- 
tive powers  in  cooler  weather,  is  too  strong  for  summer  feeding,  and 
must  be  reduced  lest  it  cause  gastro-enteritis. 

It  can  be  readily  understood  that  if  correct  feeding  for  winter. 


280  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

when  kept  up  until  hot  weather,  may  cause  summer  diarrhea,  inju- 
dicious feeding,  whether  the  fault  be  overfeeding,  irregular  hours,  or 
carelessness  in  mixing  the  food,  is  also  an  important  factor  in  its 
causation. 

Bottle-fed  babies  are  the  chief  sufferers,  but  the  disease  is  not 
extremely  rare  in  summer  in  nursing  infants  who  are  kept  too  much 
at  the  breast.  This  is  usually  because  the  mother  allows  the  infant 
to  nurse  Mdienever  it  is  fretful,  under  the  impression  that  it  is  hungry, 
when  in  reality  it  is  thirsty  and  requires,  not  breast  milk,  but  water. 

Mother's  milk  is  practically  sterile,  but  the  artificially  fed  infant 
must  take  a  milk  which  is  often  contaminated  and,  even  though 
sterilized,  may  contain  toxins  generated  by  bacteria  or  introduced  into 
the  milk  through  poisonous  weeds  the  cow  has  eaten. 

In  institutions  epidemics  occur  even  among  breast-fed  infants,  so 
that  the  possibility  of  direct  contagion  must  be  recognized,  although 
it  is  probably  a  potent  factor  only  in  the  production  of  summer  diarrhea 
when  children  are  closely  segregated,  being  transmitted  by  means  of 
soiled  diapers,  wash  rags,  towels,  etc.  When,  however,  all  the  children 
in  a  ward  contract  the  disease  simultaneously,  the  cause  is  most  likely 
to  be  found  in  some  unfit  article  of  food. 

The  children  of  the  poorer  classes  are  especially  prone  to  the  disease, 
its  frequency  and  severity  diminishing  with  improvement  in  hygiene 
and  environment.  Overcrowding  and  poor  food  account  in  large 
measure  for  the  number  of  cases  in  tenement  houses  and  congested 
districts.  Age  is  also  a  predisposing  factor,  since  the  majority  of  cases 
are  seen  in  children  less  than  two  years  old,  probably,  and  chiefly, 
because  of  injudicious  feeding  at  this  time  of  life. 

Pathology. — In  many  instances  there  is  nothing  characteristic  in  the 
appearance  of  the  stomach  and  intestines,  and,  even  when  present, 
the  lesions  are  varied  and  fail  to  correspond  exactly  with  the  nature 
and  severity  of  the  symptoms.  As  a  rule,  the  duodenum  and  jejunum 
show  no  pathological  lesions,  but  in  the  colon  and  the  distal  end  of 
the  ileum  there  may  be  evidences  of  catarrhal  inflammation  through- 
out the  mucosa,  with  here  and  there  a  congested  area,  superficial 
erosion,  or  ulceration.  There  is  an  excessive  outpouring  of  mucus 
which  bathes  the  mucous  membrane,  while  the  solitary  follicles  and 
Peyer's  patches  are  hyperplastic,  or  in  some  instances  ulcerated. 

As  a  rule,  the  lesions  are  most  marked  in  the  large  intestine,  and 
almost  invariably  there  is  hyperplasia  of  the  mesenteric  lymph  nodes. 
The  stomach  and  intestines  are  dilated,  distended  with  gas,  and  con- 
tain undigested  food  and  mucus. 

Microscopic  examination  of  the  mucous  membrane  shows  that  the 
epithelium  is  degenerating  and  desquamating,  and  bacteria  may  be 
detected  under  the  epithelial  layers.  A  pseudomembrane  sometimes 
forms  and  covers  a  considerable  area.  The  changes  in  the  viscera 
comprise  cloudy  swelling  of  the  renal  tubular  epithelium,  fatty  degen- 
eration of  the  hepatic  cells,  and  degenerative  changes  in  the  cells 
of  the  nerve  centres. 


ACUTE  GASTRO-ENTERITIS— SUMMER  DIARRHEA         281 

Symptoms. — In  mild  cases  of  summer  diarrhea  the  child  has  mod- 
erate fever,  passes  three  or  four  loose  curdy  greenish-yellow  stools 
a  day,  and  may  vomit  several  times  daily  after  feeding.  As  a  rule, 
it  is  restless  and  irritable,  and  may  occasionally  cry  out  with  colicky 
pain.  There  is  no  desire  for  food,  yet  the  child  shows  no  prostration, 
and  at  no  time  seems  seriously  ill. 

This  type  of  the  disease,  however,  is  not  so  grave  as  the  usual 
acute  form,  which  presents  a  far  different  picture.  The  onset  is  quite 
sudden,  and  is  marked  by  persistent  vomiting  and  frequent  bowel 
movements  which  at  first  consist  of  fecal  matter,  but  subsequently 
contain  mucus  and  blood,  and  little  else.  The  stomach  may  or  may 
not  reject  food;  but  the  appetite  is  so  impaired  that  there  is  rapid 
ema6iation.  There  may  be  severe  pain,  caused  by  the  distention  of 
the  abdomen  and  the  gas  and  tenesmus  which  accompany  each  bowel 
movement.  The  temperature  range  is  from  103°  to  105°  F.  at  the 
onset  of  the  attack,  but  may  drop  to  100°  or  101°  F.  after  several  days 
of  diarrhea. 

The  infant  is  prostrated,  restless,  gets  but  little  sleep,  and  takes 
practically  no  nourishment.  Moreover,  as  a  result  of  the  constant 
straining  at  stool,  it  may  suffer  from  prolapse  of  the  rectum.  The 
buttocks  become  excoriated,  the  thighs  may  be  eczematous  because 
of  the  irritation  of  the  frequent  bowel  movements,  which  may  aggre- 
gate from  fifteen  to  twenty-five  a  da3\ 

The  heart  may  also  show  signs  of  weakening  and  the  pulse  become 
feeble;  but  unless  the  infant  is  in  poor  physical  condition  at  the  onset 
because  of  malnutrition,  rachitis,  pertussis,  or  other  constitutional 
devitalizing  disease,  death  does  not  ensue  except  in  the  very  severe  or 
neglected  cases.  If  the  child  is  going  to  recover,  a  gradual  amelioration 
in  the  severity  of  the  symptoms  is  noticed,  the  stools  decrease  from 
twenty  to  ten  daily,  and  contain  less  mucus  and  more  fecal  matter. 
Vomiting,  if  persistent  during  the  attack,  gradually  diminishes  in 
frequency  and  severity,  and  the  stomach  may  retain  a  little  light 
nourishment.  In  fatal  cases  the  diarrhea  continues;  the  stools  contain 
nothing  but  mucus  and  blood;  the  high  temperature  and  extreme 
prostration  indicate  severe  toxemia;  and  death  follows  from  con- 
vulsions  and  coma  or  exhaustion. 

In  some  cases  neither  death  nor  recovery  ensues  immediately,  but 
the  acute  gastro-enteritis  passes  into  a  subacute  stage,  with  cessation 
of  vomiting,  moderately  copious  diarrhea,  mucus  stools,  and  steady 
loss  of  weight.    There  may  or  may  not  be  colic. 

The  infant  is  usually  very  restless  or  apathetic.  The  abdomen  is 
sunken  or,  in  rare  cases,  distended;  the  spleen  and  liver  are  enlarged; 
the  heart  sounds  are  weak;  albuminuria  is  usually  present,  and  is 
due  in  most  instances  to  cloudy  swelling  of  the  tubular  epithelium 
since  acute  nephritis  is  rare.  The  blood,  as  a  rule,  show^s  a  leuko- 
cytosis of  15,000  to  20,000,  with  a  decided  increase  in  the  polynuclear 
leukocytes;  in  severe  cases  these  figures  may  be  much  higher  unless 
the  system  is  too  weak  to  react,  and  then  leukopenia  is  present. 


282  DISEASES  OF   THE  GASTEO-TXTESTINAL   TRACT 

Holt  describes  an  acute  intestinal  intoxication  in  which  there  is  no 
diarrhea  but,  on  the  contrary,  the  child  is  constipated.  To  quote 
from  his  article: 

"These  cases  are  puzzling  and  frequently  most  serious,  but  for- 
tunately they  are  not  of  common  occurrence.  I  have,  however,  seen 
several  striking  examples  with  very  high  temperature,  grave  nervous 
symptoms,  and  sometimes  marked  abdominal  distention,  in  which 
it  seemed,  almost  impossible  to  move  the  bowels  by  drugs.  Castor 
oil,  calomel,  and  salines  have  in  some  cases  been  tried  in  succession 
in  four  or  five  times  the  ordinary  doses  without  the  slightest  effect, 
even  when  supplemented  by  frequent  intestinal  irrigation.  It  has 
sometimes  been  nearly  two  days  before  free  movements  were  finally 
produced.  These  are  often  exceedingly  foul.  It  is  somewhat  diffi- 
cult to  explain  such  cases.  There  seems  to  exist  for  the  time  almost 
complete  intestinal  paralysis.  The  toxic  materials  are  locked  up  in 
the  small  intestine,  for  the  colon  is  frequently  quite  empty." 

Diagnosis.— The  diagnosis  of  acute  gastro-enteritis  is  not  difficult, 
especially  in  those  cases  which  occur  during  the  summer  months; 
but  the  differentiation  between  this  disease  and  acute  intestinal 
indigestion,  or  ileocolitis,  can  be  made  only  after  several  days'  study 
of  a  case,  since  at  the  onset  the  three  diseases  present  like  symptoms. 
The  severity  of  the  s^Tnptoms  in  acute  infectious  diarrhea  is,  perhaps, 
the  most  significant  dift'erentiating  point  between  that  disease  and 
acute  indigestion. 

On  the  other  hand,  if  the  symptoms  become  aggravated  and  there 
is  pain  with  persistent  high  temperature  after  several  days  of  diarrhea, 
ileocolitis  is  suggested  rather  than  summer  complaint.  Since  the 
exanthemata  are  frequently  ushered  in  by  premonitory  diarrhea  and 
vomiting,  one  should  always  reserve  the  diagnosis  of  infectious  diarrhea 
until  several  days  have  elapsed  without  the  appearance  of  a  rash. 
A  careful  examination  of  the  chest  should  be  made  for  physical  signs 
of  pneumonia,  and  of  the  abdomen  for  rose  spots  and  enlargement  of 
the  spleen,  since  in  both  typhoid  and  pneumonia  diarrhea  may  be 
the  predommant  initial  symptom. 

In  severe  cases  of  infectious  diarrhea  there  may  be  distinct  signs  of 
meningeal  irritation  from  toxemia;  consequently,  in  meningitis  with 
diarrhea  the  diagnosis  of  the  meningeal  condition  should  be  made  only 
tentati^'ely  until  the  diarrhea  has  subsided. 

Course  and  Prognosis. — An  infant  previously  healthy,  attacked  by 
a  mild  summer  diarrhea,  usually  puts  forth  its  powers  of  resistance, 
and  recovery  follows  in  the  coiuse  of  a  week  or  so;  but  acute  gastro- 
enteritis yields  a  high  mortality  rai;e  among  the  weak,  anemic,  poorly- 
nourished  children  of  the  slums.  In  severe  cases  the  outcome  depends 
to  a  large  extent  upon  the  physical  condition  of  the  child;  but  the 
presence  or  absence  of  complications,  such  as  nepliritis,  broncho- 
pneumonia, or  ulceration  of  the  intestines,  also  affects  the  chances 
of  recovery.  In  a  favorable  case  the  active  symptoms  should  subside 
within  a  week,  but  diarrhea  may  persist  for  a  month.     The  prospect 


ACUTE  GASTRO-ENTERITISSUMMER  DIARRHEA         283 

of  iTCovcry  is  also  oreatl\'  proiiiolcd  hy  instituting-  proi)er  treatment 
immediately,  and  remoN'inji;  the  eliild  From  its  crowderl,  unhvgienie 
surromidings  to  the  seashore  or  country.  In  the  fatal  cases  death 
usually  supervenes  between  the  seventh  and  fourteenth  days.  ]\Iany 
of  the  chronic  cases  die. 

Treatment. — Proph\'laxis  has  done  far  more  to  reduce  the  mortality 
in  infants  during  the  summer  than  we  may  ever  hope  to  accomplish 
by  the  most  skilful  treatment;  therefore  a  thorough  understanding 
of  preventive  measures  against  summer  diarrhea  is  of  more  vital 
importance  than  the  actual  management  of  a  case. 

The  breast-fed  infant  should,  if  possible,  never  be  weaned  during 
the  summer  months.  On  the  contrary,  the  mother  should  continue 
to  nurse  her  baby,  and  with  strict  regularity  as  to  mtervals.  Par- 
ticular attention  should  be  paid  to  this  phase  of  nursing  in  the  summer, 
for,  owing  to  the  hot  weather,  the  infant  is  constantly  fretting  from 
thirst,  but  is  too  often  given  the  breast  instead  because  the  mother 
believes  it  to  be  hungry.  In  this  way  the  amount  of  food  is  increased 
during  the  hot  weather  instead  of  diminished,  as  it  should  be,  and 
gastro-intestinal  disturbances  result.  Water  that  has  been  boiled 
should  be  given  freely,  and  if  this  be  done  the  number  of  feedings  may 
be  decreased  during  the  summer  months. 

The  breasts  should  be  kept  perfectly  clean,  and  the  nipples  cleansed 
before  and  after  each  feeding  with  boric  acid  solution.  The  baby's 
mouth  may  be  kept  clean  by  giving  after  each  nursing  a  spoonful  of 
boiled  water. 

Fissured  nipples  and  caked  breasts  are  a  potential  source  of  infec- 
tion, and  warrant  the  removal  of  the  infant  from  the  breast  until  the 
condition  is  relieved.  These  few  precautions,  together  with  the 
hygienic  measures  outlined  below,  will  serve  to  protect  the  breast-fed 
infant  from  summer  diarrhea. 

Far  greater  care  must  be  exercised  to  insure  the  safety  of  the  bottle- 
fed  infant  during  the  hot  summer  months.  In  the  first  place,  the  purity 
of  the  milk  should  be  guaranteed,  and,  if  possible,  but  a  few  hours 
should  elapse  between  the  milking  period  and  the  time  the  milk  is 
used.  Regardless  of  its  purity,  if  the  farm  is  located  at  a  considerable 
distance  from  the  consumer,  the  milk  should  be  either  pasteurized  or 
sterilized  at  home  before  using  it  for  the  infant,  and,  as  many  babies 
are  taken  to  the  mountains,  country,  or  seashore  in  summer,  it  is  often 
necessary  to  do  this  with  the  milk. 

Cleanliness,  of  the  nursing  bottle  is  also  absolutely  essential.  It 
should  be  washed  thoroughly  with  a  bottle  brush  after  each  using. 
The  nipples  must  be  boiled  each  day,  and  kept  in  a  saturated  solution 
of  boric  acid  until  needed  for  use.  It  is  well  to  decrease  the  quantity 
of  each  feeding  by  about  one-half  in  real  hot  weather,  and  the  strength 
of  the  formula  may  also  be  reduced  to  considerably  below  the  standard 
for  a  normal  infant.  As  a  general  rule,  the  less  frequent  the  feedings 
the  better  the  infant's  digestion,  and  in  the  summer,  particularly, 
three-  or  four-hour  intervals  between  feedings  are  sometimes  advisable. 


284  DISEASES  OF   THE  GASTRO-IXTESTIXAL   TRACT 

The  child's  clothing  and  IxmIv  should  also  he  kept  absolutely  clean, 
and  a  bath  given  once  or  twice  daily.  It  should  be  kept  out  of  doors 
in  a  cool  place  all  day  long,  but  direct  exposure  to  the  sun  is  very 
dangerous,  and  must  be  avoided.  At  night  it  shotild  sleep  in  a  cool, 
well-ventilated  room,  and  be  well  protected  against  drafts.  When- 
ever possible  young  children  and  mfants  should  be  sent  away  to  the 
seashore  or  mountains  for  the  summer  months,  preferably  to  coast 
resorts  because  of  their  equable  climate. 

The  stools  of  these  infants  should  be  carefully  disinfected  with  5 
per  cent,  carbolic  acid  solution  before  being  disposed  of,  and  the 
diapers  thoroughly  washed  and  disinfected  before  using  them  the 
second  time.  Better  still  is  a  cheap  napkin  that  can  be  destroyed 
after  use.  Cleanliness  on  the  part  of  the  mother  or  nurse  is  essential 
to  prevent  contamination  of  the  food  by  her  hands,  since  reinfection 
from  this  source  may  happen. 

Every  case  of  diarrhea  or  digestive  disturbance  occurring  m  babies 
during  the  summer  must  be  considered  serious,  and  prompt  measures 
taken  for  its  cure.  Feeding  must  be  stopped  at  once,  and  a  purgative, 
preferably  castor  oil,  should  be  administered.  ]Milk,  especially,  should 
be  withlield  for  several  days,  even  from  the  breast-fed  infant,  and  for 
the  first  twenty-four  to  forty-eight  hoiu-s  nothing  but  boiled  water 
given.  This  can  be  taken  as  frequently  as  desired.  If  improvement 
is  noted  on  the  second  day,  and  the  infant  seems  hungry,  weak  barley- 
water  or  albumen-water  may  be  given,  one  or  two  ounces  at  a  time 
every  three  hours  for  a  day  or  so,  after  which  breast  feeding  may  be 
resumed.  The  baby  should  nurse  for  only  three  to  five  minutes  at 
first,  and  there  should  be  an  interval  of  three  or  four  hours  between 
the  feedings.  If  improvement  continues,  the  length  of  the  nursing 
period  may  be  gradually  increased  until  the  child  nurses  full  time. 
If,  on  the  other  hand,  the  symptoms  grow  worse  when  the  infant  is 
put  to  the  breast,  nursing  should  again  be  stopped  for  several  days, 
when  another  attempt  at  breast  feeding  may  be  made. 

The  artificially  fed  infant  may  be  deprived  of  food  for  an  even 
longer  time  than  the  nursling,  and  if  there  are  no  visible  signs  of 
improvement,  all  nourishment,  especially  milk,  may  be  withheld 
for  several  days  or  even  a  week,  and  nothing  but  albumen-water  or 
weak  barley-water  permitted.  Water  may  always  be  given  freely, 
but  barley-water  and  egg  albumen  should  be  allowed  only  when  the 
stomach  becomes  retentive,  and  then  in  one-half  the  usual  amount 
for  a  child  of  a  given  age. 

The  strength  of  the  food  must  be  increased  cautiously,  and  it  is 
well  to  keep  the  child  on  weak  broths,  beef  juice,  rice-water,  barley- 
water,  or  predigested  preparations  for  a  week  or  more  before  attempt- 
ing to  give  milk.  Eiweiss  milk  is  very  well  borne  in  some  cases; 
skimmed  milk,  well  diluted,  may  be  tried  at  first ;  but  no  attempt  should 
be  made  to  give  milk  until  the  stools  show  their  normal  characteristics. 

A  good  way  in  which  to  resume  milk  feedmg  is  to  add  a  teaspoonful 
of  milk  to  each  feeding;  then,   if  no  untoward  s^-mptoms  develop 


ACUTE  GASTRO-ENTERITIS— SUMMER  DIARRHEA         285 

gradually  to  increase  the  amount  of  milk  until  a  formula  may  be  given. 
The  strength  of  this  formula,  however,  should  be  much  below  that 
given  to  the  same  child  when  well,  and  only  one-half  the  usual  cjuan- 
tity  should  be  allowed  at  a  feeding.  If  a  whey-cream  mixture  is  well 
borne,  this  may  be  given  with  barley-water  or  rice-water  and  sugar 
of  milk.  It  is  generally  advisable  to  peptonize  the  milk  in  order  to 
insure  its  assimilation;  for  malnutrition  is  usually  extreme,  and  the 
prognosis  frequently  depends  upon  the  infant's  ability  to  utilize  its 
nourishment. 

Recent  investigations  have  shown  that  if  the  infectious  organism 
is  the  colon  bacillus,  the  Bacillus  dysenterise,  or  the  streptococcus,  a 
carbohydrate  diet  will  aid  in  effecting  a  cure,  while  a  protein,  fat-free 
food  is  more  beneficial  when  the  diarrhea  is  caused  by  the  gas  bacillus 
and  its  allied  organisms.  Further  laboratory  investigations  are  neces- 
sary before  these  finer  points  in  dietetic  management  can  be  applied. 
In  particularly  stubborn  cases  where  attempts  at  feeding  are  ineffec- 
tual, dextrinized  cereals  and  preparations,  such  as  Keller's  malt 
soup,  offer  nourishment  in  the  form  easily  digested  and  assimilated. 
Better  still,  an  effort  should  be  made  to  secure  a  wet-nurse,  since  breast 
milk  is  the  most  easily  digested  and  highly  nutritious  food  the  infant 
can  take. 

In  no  case  should,  the  strength  or  quantity  of  the  food  be  increased 
rapidly,  owing  to  the  danger  of  relapse.  Reinfection  can  only  be 
avoided  by  careful  after-treatment  and  strict  regulation  of  the  diet. 
In  feeding  children  during  the  summer  it  is  a  good  rule  never  to  give 
them  as  much  as  they  desire,  and  never  to  encourage  them  to  eat 
when  they  display  no  appetite. 

Hygienic  Management. — Next  in  importance  to  the  dietetic  treat- 
ment of  acute  gastro-enteritis  is  its  hygienic  management.  The  child 
should  be  kept  in  the  open  air,  if  possible,  or  in  a  cool  room  which 
is  sunny  and  well  ventilated.  The  clothing  should  be  very  scanty, 
and  in  extremely  hot  weather  a  diaper  is  all  that  is  necessary.  A  bath 
should  be  given  at  least  once  or,  better,  twice  a  day.  The  buttocks 
and  thighs  should  either  be  anointed  with  sterile  vaselin  or  powdered 
with  boric  acid  to  prevent  chafing  and  eczema  from  the  irritation  of 
the  frequent  stools. 

These  hygienic  measures,  while  essential  and  sometimes  effectual 
in  ameliorating  summer  diarrhea,  should  be  carried  out  at  home  onlv 
when  the  child  cannot  be  sent  away;  for  immediate  removal  of  the 
city  child  to  seashore  or  mountains  offers  a  far  better  chance  for 
improvement  than  any  hygienic  measures  employed  at  home.  The 
nurse  or  mother  should  be  instructed  to  observe  the  strictest  cleanli- 
ness with  regard  to  the  child  and  its  food  and  clothing  in  order  that, 
once  cured  of  the  disease,  reinfection  does  not  occur. 

Symptomatic  and  Medicinal  Treatment. — Of  the  acute  symptoms 
vomiting  and  diarrhea  often  call  for  immediate  relief.  If  the  attack 
be  especially  severe,  stimulation  may  be  necessary.  As  a  rule,  vomit- 
ing is  not  exhausting,  and  ceases  if  food  is  witliheld;  but,  if  it  per- 


2SG  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

sists,  the  stomach  should  be  washed  out  with  warm  sahne  sohition. 
It  is  scarcely  ever  necessary  to  repeat  this  procedure,  since  one  wash- 
ing not  only  checks  vomiting  but  cuts  short  the  attack.  If  lavage  is 
of  no  benefit  emetics,  such  as  warm  mustard  water  in  large  quantities, 
or  syrup  of  ipecac  in  ^-  to  1-dram  doses,  should  be  administered  to 
evacuate  the  stomach. 

Since  diarrhea,  like  vomiting,  is  a  conservative  process  at  the 
onset  of  acute  gastro-enteritis,  increased  evacuation  of  the  bowels 
should  be  promoted  by  the  administration  of  a  purgative  to  clean  them 
out.  Castor  oil  is  probably  the  best  drug  for  this  purpose;  but  calo- 
mel or  a  saline  may  be  amply  effectual.  The  proper  dose  of  castor 
oil  would  be  2  drams  for  an  infant  of  six  months,  4  drams  for  a  one- 
year-old  child,  and  an  additional  dram  for  each  year  of  age  above  this. 
One  grain  of  calomel  is  sufficient  for  the  infant  of  one  or  two  years, 
and  may  be  given  in  tV  of  a  grain  dose  every  hour.  ^Magnesium 
citrate  should  be  administered  in  dram  doses  diluted  with  water, 
while  the  sulphate  of  magnesium  is  retained  best  by  the  stomach  if 
the  usual  dose  of  1  dram  is  given,  well  diluted,  and  in  small  portions 
at  frequent  intervals. 

In  addition  to  free  catharsis,  colonic  irrigations  are  of  great  benefit 
in  cleaning  out  the  lower  bowel,  as  well  as  in  stimulating  peristalsis 
and  supplying  fluid  for  absorption  by  the  gut.  They  should  be  given 
daily,  or  even  twice  a  day,  at  the  onset  of  the  attack,  using  a  pint  of 
normal  salt  solution  for  very  young  infants  and  a  quart  each  time  for 
older  children.  If  tenesmus  is  severe,  starch  enemata  may  be  used 
temporarily  in  place  of  the  saline  solution,  and  cocaine  suppositories 
each  containing  i  to  |^  grain  may  be  inserted  after  the  irrigation. 
Care  should  be  taken  that  the  temperature  of  the  solution  when  used 
is  at  least  one  degree  above  that  of  the  body;  for,  especially  in  weak 
infants,  and  if  the  fluid  is  cold,  irrigation  may  be  followed  by  marked 
depression  and  even  collapse.  When  the  stomach  does  not  retain 
food,  nutrient  enemata  may  be  given,  and  salt  solution  administered 
by  slow  proctoclysis. 

Despite  the  colonic  irrigations  it  may  become  evident  during  the 
course  of  an  attack  that  toxins  are  again  being  absorbed  from  the 
intestinal  tract;  and  when  this  happens  free  purgation  is  again  indi- 
cated. If  stimulation  is  necessary,  atropine  sulphate  and  strychnine 
sulphate  may  be  given  in  tttt  to  ytq-  of  a  grain  dose  hypodermically, 
or  1  to  5  minims  of  camphorated  oil  may  be  admmistered  in  the 
same  manner.  Alcohol  in  the  form  of  brandy  or  whisky  is  also 
^'aluable  if  given  in  10-  to  30-drop  doses  every  two  hours  when  col- 
lapse seems  imminent,  but  should  not  be  used  routinely  in  every 
case.  Hypodermoclysis  has  been  employed  with  success  in  cases  of 
threatened  collapse;  but,  unless  great  care  is  taken  to  prevent  infec- 
tion by  sterilizing  the  solution  and  apparatus  used,  an  abscess  may 
form  at  the  site  of  injection  and  prove  a  serious  complication. 

Hot  baths  are  very  stimulating,  but  the  water  must  be  hot  enough 
to  bring  about  a  reaction  yet,  at  the  same  time,  not  burn  the  patient. 


ACUTE  ENTEROCOLITIS  287 

The  child  should  not  be  allowed  to  remain  in  the  water  more  than 
three  to  five  minutes,  and  should  be  carefully  protected  from  draughts 
after  the  bath. 

The  use  of  drugs  in  summer  diarrhea  for  other  purposes  than 
purgation  and  stimulation  does  not  appreciably  affect  the  course  or 
duration  of  the  disease;  but  the  administration  of  such  intestinal  anti- 
septics as  bismuth,  salol,  and  resorcin  is  always  advisable  since  they, 
at  least,  inhibit  bacterial  growth.  To  be  effectual  subnitrate  of  bis- 
muth must  be  given  in  5-  to  10-grain  doses  every  two  hours  to  a  child 
from  one  to  two  years  of  age.  Salol  and  sodium  salicylate  are  less 
well  borne  by  the  stomach,  but  may  be  given  in  1 -grain  doses  every 
two  hours  to  infants  of  one  year  and  over.  Resorcin  may  cause  vomit- 
ing; but  if  small  doses  of  ^  to  1  grain  are  administered  every  two  or 
three  hours  to  an  infant  one  year  old,  the  stomach  may  be  able  to 
retain  it.  Sulphur  given  in  the  same  manner  is  equalh'  effective  and 
less  liable  to  provoke  vomiting. 

Because  of  its  constipating  effect,  opium  should  never  be  used  until 
the  intestinal  tract  has  been  thoroughly  purged,  unless  pain  is  so 
severe  that  coUapse  is  threatened.  Later  in  the  course  of  summer 
diarrhea,  when  it  becomes  advisable  to  check  the  number  of  bowel 
movements,  paregoric  may  be  given  once,  twice,  or  oftener  daily  in 
5-  to  10-drop  doses  to  the  child  of  one  to  two  years;  or  Dover's 
powder,  i  of  a  grain,  in  repeated  doses  every  three  hours  until  relieved. 
Morphine  should  be  resorted  to  only  when  agonizing  pain  requires 
instant  relief,  and  in  these  cases  4V  to  3V  of  a  grain  of  the  sulphate 
may  be  administered  hypodermically. 

ACUTE   ENTEROCOLITIS. 

Acute  enterocolitis  is  an  inflammation  of  the  small  and  large  intes- 
tines caused  by  the  same  factors  which  give  rise  to  summer  diarrhea, 
but  differing  from  that  disease  pathologically  in  being  sometimes 
accompanied  by  quite  distinct  ulcerations  in  the  bowels.  This  affec- 
tion is  also  characterized  by  the  passage  of  blood-streaked  mucus 
stools  with  violent  tenesmus,  so  that  it  may  be  mistaken  for  true 
dysentery.  As  a  matter  of  fact,  severe  cases  of  acute  enterocolitis 
cannot  be  differentiated  from  dysentery;  but,  as  a  rule,  the  symptoms 
are  much  milder. 

Etiology. — iVcute  enterocolitis  is  a  disease  of  infancy,  but  few  cases 
being  seen  in  later  childhood.  It  is  most  common  among  children  of 
the  poorer  classes,  hence  improper  food,  unhygienic  surroundings, 
lack  of  fresh  air,  uncleanliness,  and  segregation  are  evidently  among 
the  chief  predisposing  factors.  The  majority  of  cases  occur  during 
the  summer  months,  and  in  children  whose  physical  resistance  has 
been  impaired  by  an  attack  of  acute  gastro-enteritis  or  some  other 
gastro-intestinal  disturbance.  Syphilis,  tuberculosis,  rachitis,  and 
other  chronic  systemic  conditions  predispose  a  child  to  enterocolitis; 
in  many  instances  we  find  a  history  of  recent  recovery  from  broncho- 


288  DISEASES  OF   THE  GASTRO-IXTESTIXAL    TRACT 

pneumonia  or  some  acute  contagious  disease.  Numerous  investigators 
have  found  the  colon  bacillus,  the  streptococcus,  and  the  bacillus  of 
Shiga  in  large  numbers  in  the  stools  of  these  cases;  therefore  we  are 
justified  in  believing  that  acute  enterocolitis  is  mfectious  in  origin. 

Pathology. — Two  distinct  types  of  acute  enterocolitis  are  demon- 
strated by  postmortem  findings.  In  the  catarrhal  form  the  lesions 
are  mild,  and  resemble  those  found  in  the  intestmes  in  cases  of  acute 
gastro-enteritis.  The  mucous  membrane  of  the  lower  end  of  the 
ileum  and  the  colon  is  swollen  and  hyperemic,  while  hemorrhagic 
areas  may  be  scattered  throughout.  The  lymphoid  structures  are 
swollen  and  elevated,  and  there  is  apt  to  be  marked  congestion  of 
Peyer's  patches.  The  gut  has  a  rough  feeling  due  to  epithelial 
desquamation,  and  in  the  pseudomembranous  form  of  enterocolitis 
a  false  membrane  covers  the  mucosa. 

The  ulcerative  form  is  characterized  by  the  formation  of  large 
and  small  ulcers,  particularly  in  the  large  bowel.  This  usually  occurs 
in  children  who  are  debilitated  by  preceding  illness.  Large  ulcers 
are,  as  a  rule,  quite  superficial;  but  the  smaller  ones  are  deep  and  may 
extend  down  to  the  muscular  coat  of  the  intestine.  They  are  generally 
the  result  of  involvement  of  the  lymphoid  follicles  with  subsequent 
ulceration  and  excavation.  The  most  common  lesions  found  asso- 
ciated at  autopsy  are  those  of  bronchopneumonia. 

Symptoms. — The  onset  of  acute  enterocolitis  is  usually  very  sudden, 
the  symptoms,  for  the  most  part,  being  referable  to  the  intestines. 
The  bowels  are  very  loose,  and  as  many  as  ten  to  fifteen  greenish 
watery  stools  may  be  passed  daily.  Later  the  discharges  are  com- 
posed of  mucus  and  blood,  each  movement  being  attended  by  great 
pain  and  tenesmus.  Vomiting  occurs  only  in  severe  cases,  and  in 
these  prostration  may  come  on  quickly.  The  temperature  is  elevated, 
ranging  from  103°  to  105°  F.,  the  pulse  is  correspondingly  rapid,  and 
the  respiratory  rate  accelerated.  Li  mild  cases  the  temperature  drops 
to  normal  in  a  few  days,  vomiting  ceases,  the  diarrhea  subsides,  and 
recovery  takes  place  within  ten  days  to  two  weeks  from  the  onset. 
Li  severe  cases,  however,  the  inflammation  may  become  chronic; 
or,  if  the  child's  resistance  is  very  low,  bronchopneumonia  may  set 
in  as  a  dangerous,  or  even  fatal  complication. 

Diagnosis. — The  diagnosis  of  acute  enterocolitis  is  ob^'ious  from  the 
frequent  and  painful  bowel  movements,  and  the  presence  of  mucus 
and  blood  therein.  Dysentery  may  be  closely  simulated,  but  in  the 
ordinary  case  of  acute  enterocolitis  is  ruled  out  by  the  comparatively 
mild  symptoms.  Litussusception  may  be  thought  of  in  some  cases; 
but  abdominal  palpation  and  rectal  examination  reveal  no  abdominal 
tumor,  and  the  fever  in  acute  enterocolitis  is  too  high  to  be  accounted 
for  by  intussusception. 

Prognosis. — ^Acute  enterocolitis  occurring  in  an  infant  previously 
healthy  usually  ends  in  recovery;  but  when  it  is  secondary  to  a  severe 
or  wasting  disease,  or  complicated  by  bronchopneumonia,  the  outlook 
is  grave. 


DYSENTERY  289 

Treatment. — All  feeding  should  be  stopped  immediately,  and  a 
purgative  dose  of  castor  oil  given.  If  pain  is  severe  it  may  be  neces- 
sary to  administer  -jV  to  ^V  of  a  grain  of  codeine  sulphate,  or  1  to  3 
drops  of  tincture  of  opium,  every  two  or  three  hours.  After  twenty- 
four  to  forty-eight  hours  of  starvation,  an  ounce  or  two  of  barley- 
water,  rice-water,  albumen-water,  or  weak  broths  should  be  given 
every  two  hours.  IMilk  should  be  omitted  from  the  diet  for  at  least 
a  week.  After  the  bowels  have  been  thoroughly  evacuated,  bismuth 
in  full  doses  of  10  to  20  grains,  according  to  age,  should  be  adminis- 
tered frequently  (every  two  or  three  hours)  in  order  to  control  the 
diarrhea.  When  the  number  of  stools  has  decreased  considerably 
and  other  symptoms  have  subsided,  boiled  milk,  at  first  in  small 
quantities,  may  be  added  to  the  feeding  mixture,  and  this  amount 
cautiously  increased  as  improvement  is  noted,  until  the  child  is  again 
taking  its  full  cpota  of  milk. 

If  the  constitutional  symptoms  are  severe  and  collapse  threatens, 
stimulation  may  be  required;  and  in  these  grave  cases  it  is  well  to 
support  the  child  by  10-  to  30-drop  doses  of  brandy  every  two  hours, 
together  with  atropine  sulphate,  -^-q  to  4^-g-  of  a  grain,  or  strychnine 
sulphate,  -g-g-o  to  o^q-  of  a  grain,  according  to  age.  These  children 
should  be  sent  to  the  seashore  or  mountains  as  soon  as  convalescence 
is  established,  for,  midst  healthful  surroundings,  recovery  is  more 
rapid  and  relapses  are  much  less  apt  to  occur. 

DYSENTERY. 

Dysentery  is  an  acute  diarrheal  affection  of  infancy  and  childhood, 
in  most  instances  caused  by  bacterial  invasion  of  the  intestines,  and 
occasionally  by  the  Ameba  coli.  .  In  the  United  States  amebic  dysen- 
tery is  rare,  but  sporadic  cases  occur  here  and  there  throughout  the 
country.  It  is  highly  probable  that  there  are  more  cases  of  amebic 
dysentery  among  children  in  the  southern  states  than  is  ordinarily 
presumed. 

Etiology. — In  most  cases  of  dysentery  the  essential  etiological  fac- 
tor is  invasion  of  the  gastro-intestinal  tract  by  bacteria,  of  which  the 
bacillus  of  Shiga  and  the  organism  isolated  by  Flexner  are  the  most 
important.  In  this  country  the  Shiga-Kruse  bacillus  is  but  rarely 
found  in  dysenteric  stools,  most  cases  being  due  to  the  Flexner  bacillus, 
which  is  acid-forming,  and  does  not  ferment  in  milk  or  sugar  media. 
Numerous  organisms  allied  to  the  Flexner  bacillus  have  been  isolated 
and,  no  doubt,  give  rise  to  many  of  the  milder  attacks  of  diarrhea  so 
prevalent  in  summer.  It  is  probable  that  the  colon  bacillus  and  the 
streptococcus,  when  found  in  large  numbers  in  the  stools  of  children 
with  dysentery,  constitute  a  mixed  infection.  In  temperate  climates 
bacillary  dysentery  occurs  most  frequently  during  hot  weather  either 
in  sporadic  cases  or  in  epidemics  which  affect  children  who  are  on  a 
mixed  diet.  The  amebic  form  is  usually  contracted  by  the  ingestion 
of  raw  fruits  and  vegetables  or  is  conveyed  by  contaminated  water. 
19 


290  DISEASES  OF   THE  G ASTRO-INTESTINAL   TRACT 

Pathology. — The  intestinal  lesions  are  confined  to  the  lower  portion 
of  the  ileum  and  the  colon,  and  in  every  case  the  large  bowel  is  most 
markedly  aft'ected.  The  changes  produced  vary  greatly  m  character 
according  to  the  virulence  of  the  organism,  the  resistance  of  the 
patient,  and  the  duration  of  the  attack.  In  mild  cases  there  is  merely 
catarrhal  inflammation  with  congestion  of  the  mucosa,  swelling  of 
Peyer's  patches  and,  occasionally,  hemorrhages  scattered  throughout 
the  mucous  membrane.  ]\Iore  rarely,  similar  changes  may  be  observed 
in  the  stomach  and,  exceptionally,  the  small  intestine  bears  the  brunt 
of  the  disease,  the  villi  being  so  swollen  and  edematous  that  they 
project  above  the  surface  of  the  mucosa.  The  entire  mucous  mem- 
brane is  covered  by  a  thick  tenacious  layer  of  mucus,  sometimes 
resembling  a  pseudomembrane.  In  mild  cases  microscopic  examina- 
tion reveals  epithelial  descpiamation.  In  more  severe  types  of  catarrhal 
inflammation,  superficial  ulceration  occurs.  These  ulcers  are  almost 
invariably  fomid  in  the  colon  alone,  and  while  they  may  cover  con- 
siderable areas  they  rarely  burrow  below  the  mucosa. 

The  follicular  and  ulcerative  tA'pe  of  dysentery  is  marked  by  the 
formation  of  small,  punched-out  ulcers  at  the  site  of  the  lymph  nodules 
and  solitary  follicles.  They  are  caused  by  necrosis  of  the  nodule  and 
evacuation  of  the  softened  and  disintegrated  tissue  into  the  intestine. 
In  some  cases  larger  ulcers  are  found,  formed  by  the  coalescence  of 
several  small  ones.  Follicular  ulceration  frequently  extends  to  the 
muscular  coat,  but  perforation  is  a  rarity;  as  a  rule,  the  wall  of  the 
intestine  becomes  greatly  thickened,  and  presents  a  worm-eaten 
appearance  because  of  the  ulcerated  areas.  In  the  more  severe  cases 
the  mesenteric  glands  are  congested  and  swollen,  but  there  is  no 
necrosis.  In  some  instances  the  spleen  is  enlarged,  while  in  the  amebic 
form  abscess  of  the  liver  is  occasionally  observed.  Bronchopneumonia 
is  a  frequent  complication,  and  urinary  exammation  may  reveal  a 
mild  nephritis  or,  even  more  probable,  acute  degeneration  of  the  renal 
epithelium. 

Symptoms. — An  attack  of  dysentery  usually  comes  on  suddenly- 
with  diarrhea  as  the  most  promment  symptom.  This  may  be  preceded 
by  a  feeling  of  malaise,  with  headache  and  a  rise  in  temperature. 
INIost  cases  present  the  picture  of  acute  indigestion  for  the  first  day  or 
two,  but  vomiting  is  usually  neither  severe  nor  persistent.  The  stools 
are  at  first  composed  of  fecal  matter;  but,  after  several  such  have 
been  evacuated,  they  become  watery  and  consist  for  the  most  part 
of  mucus  and  blood.  There  may  be  as  many  as  twenty  or  thirty  move- 
ments daily,  all  accompanied  by  such  pain  and  straining  that  prolapse 
of  the  rectum  is  not  uncommon.  Relaxation  of  the  sphincter  may 
also  take  place,  and  result  in  the  almost  contmuous  passage  of  small 
amomits  of  mucus  and  blood  in  which  may  be  found  shreds  of  epithe- 
lium resembling  particles  of  washed  raw  meat.  The  abdomen  is 
usually  distended  and  tender,  and  abdominal  pain  intense.  Loss 
of  fluid  from  the  tissues  causes  great  thirst,  a  dry  mouth,  and  highly 
concentrated  urine.     In  the  most  severe  forms  prostration  from  the 


DYSENTERY  291 

overwhelming  toxemia  is  alarming,  and  the  child  may  die  in  collapse 
on  the  second  or  third  day.  There  is  always  more  or  less  nervous 
depression  and  prostration,  the  degree  depending  upon  the  absorp- 
tion of  toxins.  The  pulse  is  rapid  and  feeble,  the  feet  and  hands  are 
cold,  and  convulsions  may  occur.  Emaciation  is  rapid  and  out  of 
all  proportion  to  the  duration  of  the  attack.  As  a  result  of  the  poor 
state  of  the  nutrition  bedsores  frequently  develop  in  protracted  cases. 

Amebic  dysentery  is  characterized  by  the  same  symptoms  as  the 
bacillary  form,  but  the  attacks  are  milder  and  the  disease  tends  to 
run  a  subacute  course  marked  by  periods  of  quiescence  and  exacer- 
bation. 

Diagnosis. — Dysentery  must  sometimes  be  differentiated  from 
typhoid  fever  and  intussusception,  and  in  cases  w^here  nervous  symp- 
toms predominate  it  may  simulate  meningitis.  Typhoid  fever  may  be 
ruled  out  by  a  Widal  test  and  by  examination  of  the  abdomen  for  rose 
spots  and  an  enlarged  spleen.  The  absence  of  abdominal  tumor  on 
palpation  and  rectal  examination  and  the  high  fever  we  find  in  dysen- 
tery, serve  to  exclude  intussusception.  The  diagnosis  of  dysentery 
is  based  upon  the  number  of  stools,  tenesmus  and  straining  at  stool, 
and  the  passage  of  blood  and  mucus.  Microscopical  examination 
will  reveal  the  infecting  bacteria  or  the  ameba  coli. 

Course  and  Duration. — The  usual  duration  of  an  attack  of  dysentery 
is  from  two  to  three  weeks,  but  recovery  has  been  known  to  occur 
within  ten  days.  In  fatal  cases,  as*  a  rule,  death  supervenes  in  the 
third  week,  although  very  severe  ones  may  succumb  in  a  few  days. 
When  recovery  is  about  to  take  place,  the  diarrhea  lessens  at  the 
end  of  the  first  week,  the  stools  become  less  w^atery,  and  no  longer 
contain  blood.  x\mebic  colitis  is  characterized  by  its  chronicity^ 
and  may  persist  for  a  year  or  longer. 

Complications.— Perforation  of  the  intestines  and  peritonitis  are 
extremely  rare.  In  the  amebic  type  of  dysentery  abscess  of  the  liver 
and  spleen  may  occur,  but  is  most  infrequent.  There  is  usually 
evidence  of  acute  degenerative  processes  in  the  heart,  liver,  and 
spleen.  Bronchopneumonia,  while  a  common  occurrence  in  dysentery, 
should  be  regarded  as  an  associated  condition  due  to  extreme  inanition 
rather  than  as  a  complication. 

Prognosis. — The  prognosis  should  always  be  guarded  until  after 
the  first  week  or  so  of  the  attack.  Healthy  children,  previously  well 
nourished,  usually  recover,  but  the  outlook  is  serious  if  there  has 
been  an  antecedent  gastro-enteritis. 

Treatment. — Prophylaxis  is  an  important  phase  in  the  consideration 
of  dysentery.  It  consists  chiefly  in  the  prevention  of  contamination 
of  food  and  drink.  During  the  prevalence  of  epidemics  care  should 
be  exercised  to  prevent  the  infection  of  healthy  children  by  attendants, 
and  the  patient's  hands  must  be  kept  clean  lest  he  reinfect  himself. 

At  the  onset  of  the  disease  a  full  purgative  dose  of  castor  oil  should 
be  administered,  and  this  supplemented  by  colonic  irrigations  of 
normal  salt  solution  at  a  temperature  of  100°  F.,  given  twice  a  day. 


292  DISEASES  OF   THE  GASTIiO-I NTESTI NAL   TRACT 

If  vomiting  is  severe  the  stomach  must  be  washed  out,  and  all  food 
withheld  for  from  twenty-four  to  forty-eight  hours.  Milk  is  not 
well  borne  in  these  cases,  and  for  at  least  a  week  only  barley-water, 
rice-water,  albumen-water,  or  weak  broths  should  be  allowed.  After 
the  first  few  days  one  saline  irrigation  a  day  is  sufficient,  and  even 
this  should  be  discontinued  as  soon  as  possible  because  of  its  irritating 
effect  upon  the  rectum.  If  there  be  ulceration  of  the  bowel  with  much 
bleeding  a  mild  astringent  solution,  such  as  tannic  acid,  1  dram  to 
a  pint  of  water,  or  extract  of  hamamelis,  a  half -dram  to  a  pint  of  water, 
should  be  used  instead  of  the  normal  saline  solution. 

Bismuth  subnitrate  is  excellent  to  check  the  diarrhea  after  castor 
oil  has  had  its  effect,  but  must  be  given  in  10-  to  20-grain  doses  every 
two  or  three  hours.  Opium  is  indicated  if  abdominal  pain  and  tenes- 
mus are  severe,  and  may  be  administered  in  the  form  of  Dover's 
powder,  |  to  |  of  a  grain  at  a  dose,  or  1  to  5  drops  of  the  deodorized 
tincture  of  opium  may  be  injected  into  the  rectum  in  a  solution  of 
starch.  In  giving  opium  care  should  be  taken  not  to  lock  up  the 
bowels  or  allow  the  child  to  become  stuporous;  and  before  repeating 
a  dose  the  effect  of  that  given  previously  should  be  noted.  Hot 
applications,  such  as  very  mild  mustard  plasters  or  hot-water  bags, 
placed  over  the  abdomen,  serve  to  relieve  pain,  and  if  collapse  is 
threatened  the  child  should  be  surrounded  by  hot-water  bags  and  be 
kept  well  covered.  Stimulation,  when  required,  may  be  furnished  by 
hypodermic  injections  of  atropine  sulphate,  -g^-g-  to  ^^^  of  a  grain, 
strychnine  sulphate  in  4^^^-  to  ^io^-grain  doses,  and  1  or  2  grains  of 
camphor  in  oily  solution. 

The  hygienic  care  of  infants  and  children  suffering  from  dysentery 
is  exceedingly  important,  and  whenever  possible  a  change  of  climate 
should  be  insisted  upon,  for  the  reason  that  under  proper  environment 
recovery  takes  place  more  quickly  and  relapses  are  not  as  liable  to 
occur.  Syrup  of  the  iodide  of  iron  is  a  valuable  adjunct  in  the  treat- 
ment of  the  secondary  anemia  which  follows,  and  quite  large  doses 
(15  to  30  drops)  may  be  given  three  times  a  day.  In  treating  amebic 
dj^sentery,  a  fluid  diet  should  be  maintained  for  a  longer  period  than 
is  necessary  when  treating  older  children  with  the  bacillary  form  of 
the  disease,  and  a  1  to  1000  or  a  1  to  500  solution  of  quinine  should 
be  used  for  irrigations  instead  of  salt  solution. 


CHOLERA   INFANTUM. 

Cholera  infantum  is  the  gravest  form  of  summer  diarrhea;  but, 
fortunately,  is  more  rarely  met  with  than  acute  gastro-enteritis.  It 
is  characterized  by  sudden  onset,  incessant  vomiting,  diarrhea  and 
prostration.  In  a  considerable  proportion  of  cases  it  terminates 
fatally  since  its  course  is  with  difficulty  influenced  by  treatment. 

Etiology. — Although  German  investigators  have  proven  that  faulty 
assimilation  of  fat  and  sugar  will  produce  cholera  infantum,  other 
observers   have   recently   demonstrated   that  large   numbers   of  the 


CHOLERA   INFANTUM  293 

bacillus  of  dysentery  (Flexncr),  the  colon  bacillus,  the  streptococcus, 
the  Bacillus  pyocyaneus,  or  the  Bacillus  acidophilus,  or  several  of 
these  organisms  in  combination,  are  present  in  every  case;  hence,  for 
the  present,  this  malady  must  be  considered  infectious  in  nature. 
Cholera  infantum  is  so  often  associated  with  the  use  of  impure  milk 
that  we  are  forced  to  the  conclusion  that  it  is  due  to  toxins  generated 
by  bacteria  ingested  with  the  milk,  and  that  these  are  either  liberated 
in  the  milk  before  it  is  taken  into  the  system  or  formed  by  bacterial 
growth  in  the  milk  after  it  has  reached  the  stomach  or  intestines. 

In  further  support  of  the  theory  that  impure  milk  is  the  cause  of 
the  disease  is  the  fact  that  it  appears  only  in  the  summer,  also  its 
frequency  in  bottle-fed  infants  and  its  rarity  in  the  breast-fed. 
Cholera  infantum  occurs  almost  exclusively  in  children  under  three 
years  of  age,  and  rarely  attacks  previously  healthy  babies,  so  that 
the  majority  of  cases  are  seen  in  the  marasmic,  anemic  weaklings  of 
the  slums  whose  nutrition  is  reduced  and  health  impaired  by  over- 
crowding, unhygienic  surroundings,  lack  of  fresh  air,  and  unsuitable 
food. 

Pathology. — The  postmortem  findings  are  few  and  insignificant  in 
comparison  with  the  symptoms.  At  death  emaciation  is  extreme;  the 
abdomen  is  retracted,  the  eyes  are  sunken,  the  skin  lies  in  folds;  yet 
the  gastro-intestinal  tract  may  show  evidence  of  merely  a  catarrhal 
inflammation,  with  here  and  there  minute  hemorrhages  and  super- 
ficial erosions  of  the  epithelium.  The  stomach  and  intestinal  mucous 
membranes  may  either  be  hyperemic  or  have  a  washed-out  appear- 
ance. Even  upon  microscopic  examination  they  show  nothing  more 
than  intense  inflammation  with  epithelial  desquamation.  The  liver 
cells  reveal  fatty  degeneration,  while  the  renal  epithelium  of  the 
convoluted  tubules  is  in  a  state  of  cloudy  swelling. 

Degenerative  changes  are  also  detected  in  the  heart  muscle,  while 
the  lungs  show  areas  of  consolidation  from  collapse,  also  hypostatic 
pneumonia  at  their  bases.  Because  of  the  great  loss  of  body  fluid 
which  reduces  the  amount  of  serum,  the  blood  is  thick,  concentrated, 
and  dark  red  in  color. 

Symptoms. — The  onset  of  cholera  infantum  is  very  sudden.  The 
disease  is  usually  ushered  in  by  a  rise  of  temperature  and  prostration, 
quickly  followed  by  violent  and  persistent  vomiting  and  diarrhea.  It 
generally  appears  in  an  infant  who  has  been  ill  with  a  mild,  subacute, 
or  chronic  digestive  disturbance  of  such  trivial  nature  as  scarcely 
to  cause  the  mother  to  seek  medical  advice,  but  cases  have  been 
reported  in  babies  previously  healthy. 

Vomiting  usually  precedes  the  diarrhea.  At  first  the  vomitus  con- 
sists of  undigested  food  and  sour-smelling  curds;  later,  bile  and 
mucus  are  expelled.  After  this  the  vomitus  is  composed  of  a  thin 
serous  fluid  containing  flakes  of  mucus.  Diarrhea  is  profuse  at  the 
onset,  and  after  the  intestinal  contents  are  evacuated  the  stools 
become  extremely  watery.  From  twenty  to  thirty  movements  a  day 
are  not  unusual;  but  when  the  tissues  of  the  body  are  drained  of  fluid 


294  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

the  stools  become  smaller.  Tliev'  have  a  peculiar,  musty  odor,  and 
may  be  either  yellow,  greenish,  or  gray  in  color. 

The  temperature  is  usually  high  at  first,  ranging  from  103°  to  100° 
F.,  but  may  drop  to  normal  or  subnormal  from  the  loss  of  body  heat. 
In  some  cases  it  rises  to  107°  or  108°  F.  at  death.  Thirst  is  intense, 
but  appetite  is  completely  lost,  and  food  is  refused.  The  pulse  become 
rapid  and  feeble;  the  respirations  are  shallow.  Prostration  comes  on 
quickly;  the  skin  becomes  cold  and  clammy;  the  eyes  are  sunken; 
the  abdomen  is  retracted;  the  anus  is  often  so  relaxed  that  the  passage 
of  intestinal  contents  is  continuous. 

Delirium  now  sets  in,  and  the  infant  either  dies  in  convulsions  or 
passes  into  stupor,  finally  into  coma,  and  death  supervenes.  Loss 
of  weight  is  so  rapid  and  extensive  that  it  may  amount  to  25  per  cent, 
of  the  entire  body  substance  in  forty-eight  hours.  In  a  few  cases  the 
prostration  is  not  so  extreme,  and  the  symptoms'  tend  to  subside 
after  a  day  or  so,  but  recovery  is,  unfortunately,  not  the  rule. 

Diagnosis. — In  cholera  infantum  the  diagnosis  is  largely  determined 
by  the  severity  of  the  symptoms,  since  in  some  respects  it  may  be 
closely  simulated  by  acute  gastro-enteritis;  but  the  symptoms  of  the 
latter  are  milder.  Asiatic  cholera  is  the  only  disease  which  presents 
symptoms  identical  with  those  of  cholera  infantum;  but,  fortunately, 
in  this  country  it  is  rarely  necessary  to  suspect  the  comma  bacillus  to 
be  a  causative  factor.  Typhoid  fever  and  appendicitis  may  give  rise 
to  symptoms  simulating  cholera  infantum,  but  marked  and  localized 
tenderness  and  rigidity  over  the  appendix  in  the  one  case,  and  concomi- 
tant signs  of  typhoid  fever  in  the  other,  will  exclude  cholera  infantum. 

Prognosis. — The  prognosis  is  invariably  unfavorable,  and  little  hope 
of  recovery  can  be  entertained,  even  though  the  case  be  seen  at 
the  very  onset;  for  a  favorable  termination  seems  to  depend  as  much 
upon  the  previous  state  of  health  of  the  infant  as  upon  promptitude 
or  skill  in  treatment. 

Treatment. — The  prophylaxis  of  summer  diarrhea  is  carried  out 
by  means  of  the  same  precautions  as  are  recommended  to  prevent 
acute  gastro-enteritis.  It  consists  in  the  proper  care  of  milk  during 
hot  weather,  hygienic  living  conditions  in  summer,  and  the  prompt 
and  efficient  treatment  of  every  case  of  gastro-intestinal  derangement, 
however  mild. 

When  cholera  infantum  is  suspected  the  first  indication  is  to  empty 
the  stomach  and  bow^els  by  means  of  gastric  lavage  and  colonic  irri- 
gation, using  saline  solution  at  a  temperature  of  90°  to  100°  F.  This 
may  be  repeated  every  four  to  six  hours  unless  collapse  is  threatened. 
If  prostration  is  extreme,  stimulants  should  be  given  in  the  form  of 
hypodermic  injections  of  atropine  sulphate,  -j^-q  to  4^  of  a  grain,  with 
digitalin,  yfo"  to  y^o"  of  a  grain,  or  camphorated  oil,  3  to  5  minims. 
Morphine  sulphate  is  very  efficacious  in  controlling  diarrhea  and  coun- 
teracting the  effects  of  the  toxins  on  the  nervous  system,  but  should 
be  used  cautiously  in  -g-^-  to  y^-grain  doses  hypodermically,  and  should 
■  never  be  given  if  the  infant  is  stuporous  or  comatose. 


CHRONIC  GASTRITIS  295 

Rectal  or  oral  adiiiinistration  of  stimulants  is  impossil)le;  but 
excellent  results  follow  the  su])plying  of  normal  salt  solution  to  the 
tissues  by  hypodermoclysis.  From  200  to  400  c.c.  of  warm  normal 
salt  solution  may  be  injected  into  the  loose  tissues  of  the  abdomen 
or  back  several  times  a  day.  If  the  temperature  is  subnormal,  a  hot 
mustard  bath  should  be  given,  and  the  infant  be  placed  in  bed  and 
surrounded  by  hot  water  bags. 

If  the  temperature  is  dangerously  high,  the  baby  should  be  put  in 
a  bath  with  the  water  at  100°  F.,  and  this  gradually  reduced  to  85° 
F.  An  ice-bag  should  be  kept  on  the  head,  and  rectal  injections  of 
cold  water  given.  If  the  stomach  is  at  all  retentive,  5  to  10  drops  of 
champagne  or  brandy  may  be  administered  every  hour  or  so,  and 
cracked  ice  put  in  the  mouth  to  allay  the  intense  thirst. 

When  improvement  sets  in,  an  attempt  should  be  made  to  resume 
feeding,  but  nothing  should  be  given  by  mouth  until  the  symptoms 
have  well  abated,  and  the  first  food  must  be  predigested  or  peptonized. 
If  this  is  retained,  very  weak  broths  or  w^iey  mixtures  may  be 
cautiously  given;  but  milk  should  be  withheld  for  at  least  a  week. 

As  soon  as  possible  the  child  should  be  taken  to  the  seashore,  w^here 
the  fresh  sea  air  and  change  of  surroundings  will  hasten  convalescence. 

CHRONIC   GASTRITIS. 

Chronic  gastritis  is  of  common  occurrence  in  infancy  and  childhood. 
It  is  usually  associated  with  chronic  gastro-enteritis,  and  is  secondary 
to  the  intestinal  disturbance.  Occasionally  the  intestinal  symptoms 
are  so  mild  that  the  affection  may  be  regarded  as  an  uncomplicated 
chronic  inflammation  of  the  stomach;  but  such  cases  are  rare,  and 
in  the  majority  of  them  the  intestines  sooner  or  later  become  involved. 

Etiology. — The  chief  cause  of  chronic  gastritis  is  prolonged  and 
improper  feeding,  which  results  in  successive  attacks  of  acute  gas- 
tritis, and  eventuates  in  chronic  inflammation  of  the  gastric  mucosa. 
It  is  rare  in  breast-fed  infants,  and  among  its  predisposing  factors  are 
congenital  syphilis,  tuberculosis,  and  organic  disease  of  the  heart  and 
lungs;  therefore  if  the  feeding  be  not  at  fault  one  must  suspect  some 
constitutional  dyscrasia. 

Artificially  fed  babies,  whose  digestive  systems  have  been  severely 
overtaxed  and  impaired  by  improper  feeding  in  early  infancy,  furnish 
us  with  the  majority  of  the  cases  of  gastritis  which  are  chronic  in 
nature.  Chronic  gastric  indigestion  usually  precedes  this  condition 
and  is  often  due  to  the  high  percentage  of  fats  contained  in  the  food 
which  these  babies  are  made  to  take. 

Pathology. — The  lesions  observed  in  the  stomach  of  such  infants  at 
postmortem  simply  denote  a  more  advanced  stage  of  inflammation 
than  is  seen  in  acute  gastritis.  The  stomach  is  usually  dilated,  and 
inflammatory  changes  are  diffused  throughout  its  mucosa;  in  a  cer-' 
tain  number  of  cases  in  which  the  organic  damage  is  confined  to  the 
pylorus,  the  stomach  may  be  of  natural  size.    The  mucosa  is  roughened ; 


296  DISEASES  OF   THE  GASTRO-IXTESTINAL  TRACT 

it  varies  in  color  from  a  dark  dusky  red  to  faded  gray;  it  is  covered 
with  a  layer  of  thick  tenacious  mucus.  The  submucosa  is  usually 
thickened,  while  the  muscular  coat  of  the  stomach  is  atrophied  and 
weakened. 

Atrophy  of  the  mucosa  is  sometimes  observed  in  very  early  infancy 
as  the  result  of  chronic  interstitial  changes  produced  by  long-con- 
tinued irritation  from  fermenting  residue  continually  present  in  the 
stomach.  When  sectioned  and  observed  under  the  microscope,  the 
mucosa  shows  a  degeneration  of  the  epithelium  of  the  tubules,  which 
are  either  enlarged  or  obliterated,  also  enlargement  of  the  glandular 
structures  as  a  result  of  chronic  adenitis. 

Symptoms. — The  symptoms  of  chronic  gastritis  are  both  local  and 
constitutional.  Vomiting  is  often  persistent,  and  regularly  follows 
each  feeding  period.  The  vomitus  is  composed  of  partly  digested 
food  and  foul-smelling  curds  which  may  be  bile-stained;  in  some 
instances  an  acid  mucus  is  vomited  by  these  children  in  the  morning. 
The  tongue  is  coated,  the  breath  foul.  In  addition  to  vomiting  there 
are  eructations  of  gas,  and  frequently  the  passage  of  considerable  flatus. 

In  infants  diarrhea  is  usually  present,  but  older  children  with 
chronic  gastritis  are,  as  a  rule,  constipated.  The  stomach  is  dilated 
and  tympanitic  on  percussion;  in  protracted  cases,  gastroptosis  may 
be  so  pronounced  that  the  lower  border  of  the  stomach  extends  far 
below  the  umbilicus.  The  abdomen  is  tender  on  pressure.  There 
may  be  severe  pain  after  eating,  and  colic  of  moderate  degree  is  not 
uncommon  in  infants,  although  older  children  with  chronic  gastritis 
rarely  complain  of  pain. 

The  appetite  is  either  very  poor  or  capricious,  and  the  child  looks 
anemic  and  flabby,  is  always  listless  and  fatigued,  and  very  apt  to  be 
fretful  and  peevish  during  the  day  and  restless  at  night.  There  is 
progressive  loss  of  weight;  and,  because  of  lack  of  nutrition  and  the 
impoverished  condition  of  the  blood  and  tissues,  eczematous  lesions 
of  the  skin  appear.  These  children  also  frequently  develop  a  per- 
sistent pharyngeal  cough  which,  if  severe,  leads  to  the  diagnosis  of 
tuberculosis. 

Infants  with  chronic  gastritis  quickly  become  emaciated.  As  the 
disease  progresses  all  the  symptoms  are  aggravated.  There  is  constant 
diarrhea;  vomiting  persists.  The  appetite  is  ravenous  but,  owing 
to  the  failure  of  the  digestive  system  to  assimilate  food,  loss  in  weight 
continues.  The  temperature  is  frequently  subnormal;  the  extremities 
are  often  cold  and  blue  because  of  the  poor  circulation.  Parasitic 
stomatitis  or  "thrush"  is  a  usual  accompaniment  at  this  stage  of  the 
disease,  and  the  infant  sinks  rapidly  from  exhaustion  and  malnutrition, 
being  wasted  to  a  mere  skeleton. 

In  older  children  chronic  gastritis,  while  not  quickly  responsive  to 
treatment,  does  not  present  the  serious  aspect  observed  during  infancy. 
After  infancy  it  is  of  less  frequent  occurrence,  and  the  symptoms 
differ  slightly.  Vomiting  after  meals  is  characteristic  of  chronic  gas- 
tritis in  the  child,  but  constipation  is  more  apt  to.  be  present  than 


CHRONIC  GASTRITIS  297 

diarrheal.  The  appetite  is  perverted,  and  in  many  instauees  the 
articles  of  food  craved  are  most  harmful.  The  abdomen  is  distended 
because  of  gaseous  accumulations  in  the  stomach  and  bowels.  In 
some  instances  there  may  be  fever  at  night. 

Nearly  all  these  children  show  a  chronic  inflammation  of  the  mucous 
membrane  of  the  nose  or  throat,  although  the  intestines  frequently 
escape.  The  older  child  does  not  present  the  pitiful  spectacle  that 
the  infant  with  chronic  gastritis  furnishes,  but  is  pale,  anemic,  fails 
to  gain  in  weight,  and  easily  falls  a  prey  to  acute  infections. 

Diagnosis. — In  these  cases  the  cough,  if  persistent,  and  the 
emaciation  often  suggest  pulmonary  tuberculosis;  but  a  careful  chest 
examination,  a  microscopic  study  of  the  sputum  for  the  tubercle 
bacillus,  and  a  von  Pirquet  test  will  be  of  valuable  service  in  differ- 
entiating the  two  conditions. 

Chronic  gastritis  must  also  be  differentiated  from  tuberculosis  of 
the  peritoneum,  which  it  resembles  because  of  the  persistent  diarrhea 
and  distended  abdomen.  The  absence  of  fluid  in  the  peritoneal  cavity, 
which  can  be  demonstrated  by  physical  examination,  and  a  skin  test 
for  tuberculosis  in  addition,  will  usually  exclude  the  tuberculous 
condition,  since  this  differentiation  is  not  at  all  difficult. 

The  history  of  the  case  is  of  extreme  importance  in  establishing  the 
diagnosis  of  chronic  gastritis;  while  a  test  meal  will  often  aid  us  in 
demonstrating  the  absence  of  those  digestive  changes  which  are  pro- 
duced by  an  insufficiency  of  hydrochloric  acid  and  pepsin,  together 
with  an  excessive  formation  of  lactic  and  butyric  acid,  and  a  contin- 
uous outpouring  of  mucus. 

Occasionally  a  case  of  chronic  gastritis  may  suggest,  in  the  earlier 
stages,  typhoid  fever,  but  there  is  really  little  similarity,  and  a  Widal 
test  will  usually  rule  out  this  infection.  If  congenital  syphilis  is  thought 
to  be  the  primary  cause,  a  therapeutic  test  should  be  made,  since  it 
rarely  does  harm  and  is  often  followed  by  improvement. 

Prognosis. — In  chronic  gastritis  the  prognosis  depends  largely  upon 
the  age  and  the  physical  condition  of  the  patient  when  treatment  is 
begun.  Young  infants,  in  whom  atrophic  changes  in  the  gastric 
mucosa  have  already  taken  place,  have  but  slight  chance  for  a  favor- 
able outcome.  In  children  one  or  two  years  old,  the  chances  for 
recovery  are  somewhat  more  favorable  than  in  early  infancy,  as  the 
debility  of  the  infant  renders  it  extremely  susceptible  to  secondary 
infection.  In  older  children  there  is  practically  no  actual  mortality 
from  chronic  gastritis ;  but  it  is  most  difficult  to  treat,  and  runs  a  very 
protracted  course. 

Treatment. — The  treatment  of  chronic  gastritis  depends  for  its 
results  upon  the  fidelity  with  which  the  dietary  and  hygienic  instruc- 
tions and  regulations  are  followed  by  those  in  charge  of  the  child. 
The  diet  should  receive  the  utmost  consideration.  It  is  advisable  at 
first  to  restrict  the  strength  and  amount  of  food  to  the  minimum,  and 
gradually  to  increase  it  as  improvement  is  noted. 

When  treatment  is  first  instituted  milk  should  be  withheld  from 


298  DISEASES  OF   THE  G ASTRO-INTESTINAL   TRACT 

the  infant  for  a  sliort  time,  and  barley  water,  all3uniin  water,  or  weak 
broths  sul)stituted.  If  breast-fed,  the  infant  may  be  alloAved  to 
resume  nursing  in  forty-eight  hours;  but  full  quantities  should  not 
be  permitted  until  there  is  marked  improvement  in  the  stomach 
symptoms.  Artificially  fed  babies  should  be  deprived  of  milk  for  an 
even  longer  time  than  the  breast-fed;  and,  when  milk  is  once  more 
allowed,  it  should  be  given  in  small  quantities  at  first,  and  gradually 
increased  as  digestion  improves. 

In  some  cases  digestion  is  so  very  poor  that  it  may  be  necessary 
to  give  predigested  foods,  or  to  add  a  peptonizing  powder  to  the  milk 
at  each  feeding,  and  if  nothing  given  by  mouth  is  satisfactorily 
digested,  rectal  feeding  must  be  resorted  to  in  order  to  keep  up  the 
child's  nutrition,  and  the  stomach  may  be  given  a  complete  rest. 
Older  children  rarely  require  so  great  restriction  of  diet,  but  should  not 
be  allowed  the  articles  of  food  they  prefer  if  they  are  at  all  indigestible. 

In  the  treatment  of  gastritis  a  liquid  diet  should  be  maintained 
until  the  stomach  shows  marked  improvement.  Broths  and  clear 
soups  with  dry  toast  should  first  be  given;  and,  if  this  food  is  well 
borne,  scraped  beef  or  tender  chops  may  be  permitted,  adding  a  little 
to  the  daily  menu  until  the  full  amount  of  nourishment  is  taken,  and 
thus  improve  the  poor  physical  condition  of  the  patient.  The  period 
between  nursings  should  be  lengthened  an  hour  in  infants,  and  older 
children  forbidden  to  eat  between  meals.  If  vomiting  continues 
after  restriction  of  the  diet,  the  stomach  should  be  washed  out  daily 
before  the  midday  meal  to  bring  away  the  coating  of  mucus  which 
collects  on  the  gastric  mucosa,  and  seriously  inhibits  digestion.  In 
these  cases  warm  sterile  water  or  salt  solution  may  be  used  for  washing 
the  stomach;  but  a  solution  of  sodium  bicarbonate,  5j  to  the  pint 
of  water,  is  preferable  if  fermentation  is  present. 

Drugs  alone  will  have  no  appreciable  effect  upon  chronic  gastritis; 
but  because  of  the  frequent  deficiency  of  hydrochloric  acid  in  the 
gastric  secretion  of  infants  this  acid  is  often  given  in  1-  or  2-drop  doses, 
and  may  to  advantage  be  combined  with  tincture  of  nux  vomica  in 
1-drop  doses.  Older  children  are  given  correspondingly  larger  doses 
of  these  two  drugs.  In  addition  a  daily  dose  before  breakfast  of  sodium 
phosphate  is  necessary  to  regulate  the  bowels.  Cerium  oxalate, 
2  grains,  and  menthol,  1  grain,  given  every  three  hours,  are  often 
valuable  in  controlling  persistent  vomiting. 

After  the  diet,  the  most  important  considerations  in  the  treatment 
of  a  child  with  chronic  gastritis  are  the  environment  and  living  con- 
ditions, and  proper  hygienic  surroundings  will  aid  materially  in 
hastening  the  recovery  of  these  little  ones.  An  infant  should  be  kept 
out  of  doors  all  day  on  a  bed  taken  to  the  roof,  or  it  may  be  put  on 
the  porch  in  its  coach.  Older  children  should  be  encouraged  to  play 
out  of  doors,  but  not  to  the  point  of  fatigue.  If  possible,  they  should 
be  sent  to  the  country  or  seashore  after  steady  improvement  has  set 
in,  since  relapses  are  quite  common,  and  can  be  prevented  only  by 
ideal  management  of  the  case  and;  hvs'ienic  environment. 


DILATATION  OF   THE  STOMACH  299 

DILATATION    OF    THE    STOMACH. 

Chronic  dilatation  of  the  stomach  is  quite  common  in  infancy  and 
childhood,  and  is  most  frequently  the  result  of  chronic  gastric  indiges- 
tion or  chronic  gastro-enteritis.  Acute  dilatation  of  the  stomach, 
while  less  common  than  the  chronic  form,  is  observed  oftener  in 
children  and  infants  than  in  adults. 

Etiology. — In  infants  and  young  children  the  stomach  becomes 
dilated  from  quite  trivial  causes,  but  the  condition  is  often  merely 
temporary.  Only  when  there  are  continuous  or  oft-repeated  signs  of 
gastric  derangement  does  permanent  dilatation  take  place.  Children 
with  a  constitutional  dyscrasia,  such  as  tuberculosis,  syphilis,  rachitis, 
or  marasmus,  frequently  suffer  from  dilatation  of  the  stomach  due 
to  the  atonic  condition  of  the  stomach  wall,  which  impairs  gastric 
motility,  and  results  in  the  retention  of  a  residue  and  consequent 
fermentation. 

A  less  common  cause  of  gastric  dilatation  is  an  obstruction  within 
the  gastro-intestinal  tract,  such  as  pyloric  stenosis  or  partial  obstruc- 
tion of  the  bowel.  In  a  great  many  cases  gastric  dilatation  is  the 
result  of  recurring  or  continuous  distention  of  the  stomach  due  to 
fermentative  gastric  indigestion.  A  severe  and  acute  form  of  dilata- 
tion of  the  stomach  sometimes  occurs  in  scarlet  fever,  in  typhoid 
fever,  in  pneumonia,  and  in  chloroform  poisoaing. 

Pathology. — At  postmortem  the  stomach  is  generally  found  to  be 
much  larger  than  has  been  suspected  from  clinical  evidence  during 
life.  Cases  have  been  reported  in  which  the  gastric  capacity  was 
three  times  that  of  a  normal  infant.  Chronic  catarrhal  gastritis  is 
usually  present,  and  the  thinness  of  the  stomach  wall  is  evidence  of 
considerable  atrophy  of  its  muscular  coat. 

Symptoms. — The  symptoms  presented  by  a  child  with  chronic 
dilatation  of  the  stomach  are  principally  those  of  the  associated  chronic 
gastritis.  Vomiting  is  persistent,  and  may  occur  periodically  at 
intervals  of  twelve  to  twenty-four  hours.  Mucus  may  be  vomited  in 
the  morniiig  when  the  stomach  is  empty;  but,  as  a  rule,  vomiting 
follows  the  nursing  or  feeding  period,  and  the  vomitus  contains  undi- 
gested food  or  milk  curds  from  several  preceding  feedings,  showing 
that  although  food  is  retained  in  the  stomach  much  longer  than 
normally,  digestion  is  so  faulty  that  the  stomach  contents  are  prac- 
tically unaltered  by  the  action  of  the  gastric  juice. 

The  tongue  is  coated,  the  breath  is  fetid.  The  child  either  has 
chronic  diarrhea  or  is  markedly  constipated.  Eructations  of  gas  occur 
at  frequent  intervals,  and  there  is  usually  considerable  flatus.  The 
stomach  is  ballooned,  and  tympantic  on  percussion;  the  lower  border 
may  extend  well  below  the  umbilicus.  The  abdomen  is  tender,  espe- 
cially around  the  epigastrium.  There  may  be  considerable  pain  after 
eating. 

As  a  rule  the  appetite  is  poor,  and  the  child  quickly  loses  weight, 
becomes  anemic  and  flabby  looking,  and  is  exhausted  from  lack  of 


300  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

nourishment.  It  is  apt  to  he  peevish  diu'inf^'  the  thiy  and  restless  at 
night.  Oceasionally  convulsions  are  noted.  Extreme  thirst  is  one  of 
the  few  characteristic  symptoms  of  chronic  dilatation  of  the  stomach, 
and  is  very  difficult  to  assuage.  Chronic  gastric  dilatation  gives  rise 
to  indefinite  and  vague  symptoms;  acute  dilatation  of  the  stomach 
may  manifest  itself  suddenly,  and  its  symptoms  are  of  greater  severity. 
Dyspnea  may  appear  from  pressure  of  the  distended  stomach  upon 
the  heart. 

The  infant  or  child  soon  loses  color,  and  appears  to  be  very  ill. 
Upon  percussion  the  epigastrium  is  found  to  be  tympanitic  from  the 
ensiform  cartilage  down  to  well  below  the  umbilicus;  but  it  is  diffi- 
cult to  differentiate  the  gastric  tympany  from  that  caused  by  colonic 
distention.  Acute  dilatation  of  the  stomach  to  a  moderate  degree 
often  occurs  during  infancy;  but  is  relieved  by  the  eructation  of  gas, 
and  does  no  harm  unless  repeated  too  frequently. 

Diagnosis. — When  there  is  a  history  of  long-standing  chronic  gas- 
tritis, and  a  large  area  of  tympany  is  found  over  the  epigastrium,  the 
diagnosis  of  chronic  dilatation  of  the  stomach  is  not  difficult;  but, 
unless  some  practical  method  of  gauging  the  stomach  contents  is 
used,  there  will  be  extremely  wide  variations  between  the  clinical 
estimation  of  the  degree  of  dilatation  and  the  postmortem  findings. 

In  the  case  of  an  infant  or  young  child  it  is  sometimes  possible  to 
calculate  the  capacity  of  the  stomach  by  filling  it  with  water,  and 
noting  the  amount  required.  Transillumination  may  be  a  valuable 
aid  in  outlining  the  boundaries  of  the  organ,  and  in  differentiating 
gastric  dilatation  from  colonic  distention,  w^hich  is  the  only  condition 
that  can  possibly  be  confounded  with  dilatation  of  the  stomach. 

Prognosis. — Chronic  dilatation  of  the  stomach  does  not  necessarily 
endanger  the  life  of  the  child,  but  is  often  the  cause  of  a  prolonged 
chronic  gastritis  inasmuch  as,  when  present  as  a  complication  of  a 
chronic  stomach  affection,  it  renders  treatment  very  difficult. 

This  superadded  condition  may  be  the  indirect  cause  of  death  during 
infancy  by  reducing  the  digestive  power  of  the  stomach  to  a  dangerous 
degree.  When  acute  dilatation  of  the  stomach  exists  alone,  recovery 
is  much  more  rapid;  but  in  those  cases  where  the  dilatation  is  due  to 
organic  lesions,  such  as  stenosis  of  the  pylorus,  or  congenital  stenosis 
of  the  duodenum  and  ileum,  the  outlook  is  very  unfavorable.  ' 

Treatment. — The  restriction  and  regulation  of  the  diet  is  the  most 
important  measure  for  the  relief  of  chronic  dilatation  of  the  stomach. 
The  breast-fed  infant  should  be  deprived  of  milk  for  a  day  or  so, 
and  barley-water,  albumen-water,  and  weak  broths  be  substituted. 
At  the  end  of  this  period  the  child  may  again  be  put  to  the  breast, 
but  only  for  a  few  minutes  at  each  nursing  period. 

At  first  it  is  w^ell  to  increase  the  length  of  time  between  the  feedings ; 
but  when  improvement  sets  in  the  nursing  periods  may  be  gradually 
increased  and  the  intervals  between  them  shortened,  until  the  child 
is  again  taking  its  full  quota  of  nourishment  daily.  Artificially  fed 
infants  may  be  taken  off  milk  for  a  week  or  ten  days  if  necessary; 


FYLOROSFASM  301 

if  the  digestion  be  very  poor,  the  food  may  be  either  predigested  or 
given  by  rectum. 

In  older  children  chronic  dilatation  of  the  stomach  is  never  as  serious 
as  in  infancy,  and  frequently  careful  regulation  of  the  diet  and  absten- 
tion from  pastry,  candies,  fried  and  other  indigestible  foods,  are  suffi- 
cient to  bring  about  amelioration.  The  ingestion  of  large  quantities 
of  liquids  should  be  avoided.  The  stomach  should  be  washed  out 
daily  as  long  as  vomiting  continues,  using  warm  saline  solution  or 
an  aqueous  solution  of  bicarbonate  of  soda,  3j  to  a  pint  of 
water. 

The  tincture  of  nux  vomica  is  often  of  great  value  in  the  treatment 
of  chronic  dilatation  of  the  stomach  because  of  the  atonic  condition 
of  the  stomach  M^all.  It  may  be  given  in  1-drop  doses,  three  times 
a  day,  to  a  child  of  one  year,  or  in  5-drop  doses,  three  times  a  day, 
to  a  five-year-old  child,  and  is  best  administered  at  meal  times  in 
combination  with  an  organic  preparation  of  iron. 

Children  with  chronic  dilatation  of  the  stomach  often  show  marked 
improvement  if  sent  to  the  seashore  or  country;  but  when  this  is 
impossible  much  can  be  accomplished  at  home  by  insisting  on  outdoor 
life,  and  fresh  air  and  sunshine. 

Acute  dilatation  of  the  stomach  is  often  relieved  spontaneously 
by  the  eructation  of  gas,  which  can  sometimes  be  made  more  effectual 
by  the  administration  of  a  few  drops  of  spirits  of  chloroform,  Hoff- 
man's anodyne,  or  peppermint-water.  If  stimulation  is  required, 
camphorated  oil  in  drop  doses  may  be  given  to  an  infant  hypoder- 
mically,  or  1  dram  of  brandy  and  a  half-ounce  of  black  coffee  by  rectal 
injection.  If  the  diet  is  regulated  after  the  first  attack  of  acute  dilata- 
tion of  the  stomach,  it  will  go  far  toward  preventing  further  trouble. 

PYLORO  SPASM. 

Spasm  of  the  pylorus,  while  by  no  means  a  common  aft'ection  in 
infancy,  occurs  with  much  greater  frequency  than  does  hypertrophic 
pyloric  stenosis,  although  few  cases  are  recognized.  In  the  majority 
of  instances  it  is  thought  to  be  hypertrophy  of  the  pylorus  until  the 
results  of  operation  or  the  effects  of  medical  treatment  exclude  the 
possibility  of  its  being  an  organic  lesion. 

Etiology. — Pylorospasm  is  usually  seen  in  bottle-fed  babies,  rarely 
in  the  breast-fed.  It  is  often  brought  on  by  a  sudden  change  from 
mother's  to  cow's  milk,  and  is  usually  accompanied  by  either  hyper- 
secretion of  gastric  juice  or  hyperacidity.  The  frequency  of  gastric 
disturbances  in  infancy  and  the  rarity  of  pylorospasm  make  it  evident 
that  other  contributing  factors  must  be  active  in  causing  this  condition; 
but  the  exact  nature  of  these  influences  is  as  yet  most  obscure. 

It  has  been  noted  that  the  majority  of  infants  with  pylorospasm 
are  nervous  and  excitable,  manifesting  a  hereditary  neurotic  tendency 
which  results  in  hyperirritability  of  the  pyloric  sphincter  in  common 
with  all  other  muscles  of  the  bodv.     The  normal  extreme  irritability 


302  DISEASES  OF   THE  G ASTRO-INTESTINAL   TRACT 

» 
of  muscle  tissue  in  early  infancy  probably  explains  to  a  certain  degree 
the  occurrence  of  the  disease  at  this  period. 

Pathology. — On  postmortem  examination  the  stomach  and  esopha- 
gus are  usually  greatly  dilated,  the  mucous  membrane  is  congested 
and  formed  into  folds  much  like  those  observed  in  hypertrophic 
stenosis  of  the  pylorus;  but  in  uncomplicated  cases  of  spasm  there 
is  neither  tumor  formation  nor  increase  of  tissue  at  the  pyloric  end 
of  the  stomach,  and  the  degree  of  stenosis  is  not  so  extreme. 

Symptoms. — Vomiting  is  the  chief,  and  sometimes  the  only  marked 
sjinptom  of  pylorospasm;  especially  is  this  true  in  mild  cases  where 
the  infant  is  apparently  healthy  in  every  other  respect.  Weeks  and 
even  months  may  elapse  after  birth  before  the  infant  begins  to  vomit; 
but  from  the  time  vomiting  sets  in  it  is  persistent. 

The  baby  usually  vomits  soon  after  food  reaches  the  stomach; 
either  the  stomach  contents  are  all  ejected  at  once  or  small  quantities 
are  brought  up  at  frequent  intervals.  Rarely  does  the  amount  of 
vomitus  exceed-  the  quantity  of  food  taken  at  the  last  feeding.  On 
examination  of  the  vomited  material  there  is  no  evidence  of  fermen- 
tation or  other  gastric  disturbance.  The  stools  may  be  nearly  nor- 
mal in  size,  notwithstanding  the  constipation,  and  the  child  may 
be  fairly  well  nourished  because  of  the  amount  of  food  retained  by 
the  stomach  and  passed  mto  the  intestine. 

In  serious  cases  of  pylorospasm  the  symptoms  closely  simulate 
hypertrophic  pyloric  stenosis.  Vomiting  is  severe,  and  may  be  explo- 
sive in  character.  Practically  e^'erything  eaten  is  rejected  by  the 
stomach,  so  that  the  infant  rapidly  loses  weight.  Obstinate  constipa- 
tion with  very  small  stools  is  caused  by  the  deficiency  of  digestive 
residue  in  the  intestines. 

Antiperistaltic  waves  can  be  observed  on  inspection  of  the  abdomen 
immediately  after  food  is  taken;  but  these  disappear  after  the  stomach 
contents  are  ejected  or  passed  into  the  duodenum.  Occasionally  a 
tumor  is  palpable  at  the  pylorus,  but  it  is  much  smaller  than  the 
mass  felt  in  cases  of  hypertrophic  pyloric  stenosis,  and  if  it  is  palpated 
carefully  a  change  in  size  will  be  noted  corresponding  to  the  contrac- 
tion and  relaxation  of  the  pyloric  sphmcter  (Fig.  29). 

In  mild  cases  no  peristaltic  wave  may  be  visible  and  no  tumor 
felt,  but  if  .T-rays  are  taken  after  a  bismuth  meal,  marked  inter- 
ference with  the  passage  of  the  stomach  contents  into  the  duodenum 
will  always  be  observed  (Plate  III). 

Diagnosis. — As  a  rule  the  diagnosis  of  obstruction  at  the  pyloric 
end  of  the  stomach  is  not  difficult,  but  a  severe  case  of  pylorospasm 
may  so  simulate  a  mild  case  of  hypertrophic  pyloric  stenosis,  or  a  mild 
case  of  hypertrophic  pyloric  stenosis  may  so  much  resemble  a  severe 
case  of  pylorospasm,  that  the  differentiation  is  sometimes  impossible. 

The  chief  symptoms  which  favor  pylorospasm,  however,  are  the 
slight  impairment  of  nutrition,  the  moderate " constipation,  the  fairly 
normal  gastric  digestion,  and  the  absence  of  a  palpable  tumor  of 
fixed  size  at  the  pylorus.     Although  the  s}'mptoms  of  pylorospasm 


PLATE  in 


Boy,  Aged  Four  and  One-half  Years;  Weight,  Thirty-three 
and  One-half  Pounds,  Frequent  Attacks  of  Vomiting.  Palpable 
Tumor  at  Pylorus. 

There  is  constant  irregularity  in  the  outline  of  the  pylorus,  and  upon 
palpation  under  fluoroscopic  observation  there  is  partial  fixation  as  well  as 
palpable  thickening.  At  six  hours  there  is  almost  complete  retention  of 
the  barium  meal  in  the  stomach.  In  the  erect  posture  the  stomach  does  not 
empty.  When  the  patient  lies  on  the  right  side,  the  bariuni  meal  leaves  the 
stomach   in  a    very  small  stream.     Stomach   dilated. 


PYLOROSPASM 


303 


are  much  milder  than  those  of  hypertrophic  pyloric  stenosis,  there 
is  a  marked  contrast  between  vomiting  due  to  spasm  of  the  pylorus 
and  habitual  vomiting.  In  the  latter  condition  the  child  does  not 
suffer  from  loss  of  nourishment,  the  stools  are  normal  in  size  and 
number,  and  the  vomiting,  never  projectile,  can  be  attributed  to  a 
certain  extent  to  conditions  outside  the  stomach. 

Prognosis. — In  the  majority  of  cases  the  prognosis  is  good  if  treat- 
ment is  carried  out  faithfully,  and  the  amount  of  intestinal  residue, 
as  shown  by  the  size  of  the  stools,  is  a  fah  indication  of  the  progress 
of  the  disease.  The  course  of  a  case  of  pylorospasm  is  usually  pro- 
tracted, but  recovery  under  medical  treatment  should  be  anticipated 
except  in  the  gravest  cases  where  surgical  intervention  is  sometimes 
necessarv  to  save  life. 


Fig.  29. — Pylorospasm  in  an  infant  two  months  old,  showing  peristaltic  waves. 

Treatment. — Dietetic  regulation  is  the  most  important  phase  in 
the  treatment  of  pylorospasm,  and  it  is  a  question  whether  appreciable 
results  can  be  obtained  from  any  other  therapeutic  measures.  The 
breast-fed  infant  should  be  allowed  to  nm-se  for  only  a  few  minutes 
at  a  time,  and  the  intervals  between  nursing  should  be  an  hour  longer 
than  is  normally  required  for  the  stomach  to  empty  itself.  If  the 
mother's  milk  contains  a  high  percentage  of  fat,  the  quantity  allowed 
at  each  feeding  should  be  reduced  still  further,  and  this  deficiency  in 
the  amount  of  the  feeding  made  up  by  giving  the  infant  from  a  dram 
to  a  half-ounce  of  lime-water  after  each  nursing. 

Since,  however,  it  is  most  frequently  the  artificially  fed. infant  who 
suffers  from  pylorospasm,  proper  modification  of  cow's  milk  in  these 


304  DISEASES  OF   THE  GASTRO-INTESTIN AL   TRACT 

cases  is,  perhaps,  the  most  important  consideration  in  the  regulation 
of  the  diet.  The  strength  of  the  formula  given  will  depend,  of  course, 
upon  the  age  and  weight  of  the  infant  with  pylorospasm,  just  as  in 
any  other  feeding  case;  but,  bearing  in  mind  the  fact  that  it  is  most 
desirable  to  have  as  much  of  the  stomach  contents  pass  the  pylorus 
as  possible,  an  attempt  should  be  made  to  give  a  mixture  which 
will  pass  readily  into  the  duodenum,  because  of  the  relatively  rapid 
digestion  of  its  constituents  and  the  lack  of  curd  formation. 

From  this  point  of  vieW'  it  will  be  readily  seen  that  the  carbohydrate 
content  may  be  unchanged,  masmuch  as  lactose  leaves  the  stomach 
early,  and  does  not  give  rise  to  curd  formation;  that  protein  is  better 
given  in  the  form  of  w-hey  to  prevent  so  far  as  possible  the  formation 
of  large  casein  curds;  and  that  the  fat  content  of  such  a  formula 
should  be  greatly  reduced  because  of  the  length  of  time  required  for 
the  stomach  to  empty  itself  after  a  feedmg  rich  in  fats.  Olive  oil, 
five  drops  three  times  a  day,  is  often  retained  and  well  digested,  and 
frequently  the  dose  may  gradually  be  increased  to  10  or  15  drops 
three  times  a  day.  I  have  often  seen  fat  in  this  form  retained  and 
well  digested  when  cream,  even  in  the  smallest  amounts,  could  not 
be  tolerated. 

The  addition  of  lime-water  to  such  a  formula  should  be  much  in 
excess  of  that  used  for  the  ordinary  feeding  case,  on  account  of  the 
hyperacidity  of  the  gastric  juice  in  these  cases.  It  is  the  safest  plan, 
however,  to  allow  the  degree  of  alkalinity  of  the  mixture  to  depend 
upon  the  amount  of  hyperacidity  as  determined  by  gastric  analysis, 
since  hyperalkalinity  might  prove  to  be  as  active  an  exciting  factor 
in  provoking  pylorospasm  as  hyperacidity.  Besides,  in  addition  to 
the  beneficial  effects  of  neutralizing  the  hyperacidity  of  the  gastric 
juice,  the  addition  of  an  alkali  to  the  formula  delays  the  coagulation 
of  casein  by  rennin,  and  thus  helps  to  eliminate  the  protein  curds  in 
the  gastric  contents,  and  favors  their  easy  passage  into  the  duodenum. 

It  is,  perhaps,  the  best  plan  to  reduce  considerably  the  amount 
given  at  each  feeding.  To  a  certain  extent  this  quantity  will  depend 
upon  the  size  and  age  of  the  child,  but  the  severity  of  the  symptoms 
should  also  serve  as  a  guide.  In  aggravated  cases  it  may  be  advisable 
to  give  but  a  dram  or  two  of  the  mixture  at  each  feeding,  increasing 
this  amount  gradually  as  improvement  is  noted. 

If  too  little  food  is  retained  to  nourish  the  infant  or  sustain  life,  a 
No.  15  catheter  may  be  passed  through  the  pylorus,  and  food  be  thus 
introduced  into  the  duodenum.  The  stomach  should  be  w^ashed  out 
daily  with  a  5  per  cent,  solution  of  sodium  bicarbonate.  Rectal 
injection  of  normal  salme  or  Ringer's  solution  is  also  advocated  because 
of  the  theory  that  instillation  of  salt  solution  in  the  rectum  diminishes 
the  secretion  of  the  gastric  juice. 

In  these  cases  there  are  no  drugs  which  have  any  appreciable  effect 
upon  the  frequency  or  severity  of  the  vomiting;  but  paregoric  is 
sometimes  given  in  5-  to  10-drop  doses,  and  cocaine  also  by  mouth 
in  weak  solution  for  its  anesthetizing  effect  upon  the  mucous  mem- 


HYPERTROPHIC  PYLORIC  STENOSIS  305 

brarie  of  the  stomach.  Bromide  of  soda  in  2-grain  doses,  three  times 
a  day,  tends  in  some  cas^s  to  lessen  the  tendency  to  spasm  at  the 
pylorus.  In  addition,  warm  spice  poultices  are  sometimes  applied 
to  the  epigastrium  immediately  before  and  after  feeding. 

The  majority  of  cases  of  pylorospasm  will  show  slow  but  progressive 
improvement  under  medical  treatment,  and  eventually  recover;  but 
in  a  few  instances,  despite  careful  regulation  of  the  diet  and  the  best 
attention,  an  infant  will  fail  to  improve,  and  steadily  grow  worse,  and 
then  surgical  intervention  is  warranted.  If  the  physical  condition  be 
good,  posterior  gastro-enterostomy  is  not  attended  by  high  mortality, 
and  it  offers  the  only  possible  chance  for  life. 

HYPERTROPHIC    PYLORIC    STENOSIS. 

Hypertrophic  pyloric  stenosis  is  a  condition  which  usually  occurs 
in  early  infancy,  and  is  the  result  of  congenital  hypertrophy  of  the 
sphincter  muscle  at  the  pyloric  end  of  the  stomach.  The  excess  of 
muscular  tissue  at  the  pylorus  forms  a  tumor  there  which  so  narrows 
the  inner  diameter  of  the  pyloric  orifice  that,  instead  of  measuring  3 
to  3|  mm.,  as  in  the  normal  infant,  it  will  barely  admit  a  small  probe. 
Etiology. — Hypertrophic  pyloric  stenosis  is  essentially  a  disease  of 
infancy,  and  in  more  than  50  per  cent,  of  the  cases  the  symptoms 
appear  before  the  second  week.  After  the  eighth  week  the  disease 
is  comparatively  rare.  However,  a  number  of  such  cases  have  been 
reported  in  older  children. 

I  have  recently  seen,  in  consultation  with  Dr.  Betts,  a  boy,  four 
years  of  age,  with  a  palpable  tumor  at  the  pylorus.  This  boy  was 
nursed  until  he  was  a  year  old,  and  developed  normally.  From  the 
age  of  one  to  two  years  he  gained  slowly  in  weight.  Since  he  was  two 
and  a  half  years  old,  he  has  had,  every  four  to  six  weeks,  attacks  of 
severe  vomiting  with  a  slight  fever.  These  attacks  last  ordinarily 
for  forty-eight  hours.  During  the  past  year  and  a  half  he  has  not 
seemed  as  well  or  as  strong  as  he  ought  to  be,  and  he  is  always  pale 
and  constipated.  On  December  2,  1915,  in  one  of  these  brief  illnesses, 
he  vomited  some  spinach  that  he  had  eaten  fourteen  hours  previously. 
The  .T-ray  plates  show  that  at  six  hours  there  was  almost  complete 
retention  of  the  barium  meal  in  the  stomach.  In  the  erect  posture 
the  stomach  did  not  empty  at  all;  but  when  the  patient  lay  on  the 
right  side  we  got  a  fairly  good  view  of  the  barium  meal  leaving  the 
stomach  in  a  very  small  stream.  At  twenty-four  hours  all  the  barium 
meal  was  found  in  the  colon,  the  stomach  being  entirely  empty  of  it. 
Many  of  the  cases  occur  in  the  first-born  child,  and  boys  are  more 
subject  to  the  disease  than  girls.  Observers  are  not  united  in  the 
opinion  that  the  hypertrophy  of  the  sphincter  muscle  is  congenital; 
some  insist  that  it  is  the  result  of  too  frequent  muscular  spasms  during 
the  first  few  days  of  life,  caused  by  gastric  or  duodenal  irritation. 
But  while  it  is  true  that  hyperacidity  is  usually  associated  with 
pyloric  stenosis,  no  conclusive  evidence  has  been  brought  to  light 
20 


306  DISEASES  OF  THE  GASTRO-INTESTINAL   TRACT 

that  would  lead  us  to  believe  that  the  condition  can  be  attributed 
to  improper  feeding  or  hyperacidity.  The  actual  cause  of  this  disease 
is  therefore  still  a  mooted  question. 

Pathology. — On  examination  of  the  stomach  the  pylorus  is  readily 
detected  as  a  hard  tumor  mass  the  lumen  of  which  is  so  small  that  a 
thin  probe  can  be  passed  through  only  with  difficulty.  The  stomach 
is  usually  dilated,  the  muscular  coat  hypertrophied  throughout.  The 
mucous  membrane  lining  the  stomach  is  thickened,  roughened,  cov- 
ered with  mucus,  and  also  shows  signs  of  gastritis.  In  some  cases 
the  longitudinal  folds  of  mucous  membrane  extend  into  the  pylorus, 
and  completely  occlude  that  orifice.  The  intestines  are  contracted, 
atrophic,  and,  for  the  most  part,  empty.  When  examined  under 
the  microscope,  a  longitudinal  section  of  the  pylorus  reveals  intensely 
hypertrophied  muscle  fibers,  and  also  hypertrophy  of  the  mucous 
membrane  in- this  region;  but  the  longitudinal  muscle  fibers  are  but 
little,  if  at  all,  affected. 

Symptoms. — At  birth  the  infant  with  hypertrophic  pyloric  stenosis 
is  apparently  normal,  and  usually  remains  in  good  health  for  several  , 
days  or  a  week ;  but,  sooner  or  later,  the  chief  symptom  of  this  disease 
appears,  and  the  child  vomits  persistently  after  each  feeding  without 
regard  to  what  is  fed.  Sometimes  two  or  three  feedings  are  retained, 
and  then  expelled  simultaneously.  As  the  disease  progresses  the 
vomiting  becomes  forcible  and  projectile  in  character;  it  tends  to 
persist,  and  grows  worse  despite  regulation  of  the  diet  and  all  other 
measures  instituted  to  control  it.  When  several  nursings  are  retained 
before  being  vomited  the  stomach  may  become  greatly  dilated,  and 
gastric  peristalsis  is  visible.  .  A  palpable  tumor  can  usually  be  detected 
in  the  pyloric  region,  and  easily  identified  as  the  hypertrophied  pylorus. 
Although  the  epigastrium  may  be  quite  prominent,  the  lower  abdomen 
is  concave  and  sunken  owing  to  the  fact  that  the  intestines  contain 
very  little  fecal  matter  or  food  residue,  since  it  is  impossible  for  much 
food  to  pass  into  the  duodenum.  The  infant  is  constipated  because 
of  the  lack  of  intestinal  contents,  and  in  those  cases  where  hypertrophy 
of  the  pylorus  is  accompanied  by  pylorospasm,  very  little  fecal  matter 
is  passed  from  the  time  the  disease  becomes  manifest  until  death. 
The  stools  sometimes  resemble  meconium,  and  contain  bile  and  a 
small  amount  of  food  residue.  The  loss  in  weight  is  rapid  and  exces- 
sive, and  unless  relieved  the  child  eventually  starves  to  death.  In 
a  few  weeks  the  infant  is  reduced  to  a  mere  skeleton  with  sunken  e;)  es, 
flaccid  abdomen,  and  dry  skin  and  lips.  The  large  dilated  stomach 
makes  the  epigastrium  the  most  prominent  part  of  the  body,  and  as 
the  infant  lies  on  its  back  in  a  state  of  exliaustion  peristaltic  waves, 
perhaps  several  at  a  time,  become  visible  and  can  be  seen  to  run 
slowly  across  the  upper  abdomen  from  left  to  right.  The  temperature 
is  normal  or  subnormal.  The  appetite  is  usually  ravenous,  but  there 
is  no  other  symptom  of  gastric  disturbance. 

Diagnosis. — The  diagnosis  of  a  typical  case  of  pyloric  stenosis  is 
not  difficult,  and  can  sometimes  be  made  with  reasonable  certainty 


HYPERTROPHIC  PYLORIC  STENOSIS  307 

from  a  history  of  the  vomitmg.  If  an  otherwise  healthy  breast-fed 
infant  vomits  persistently,  having  begun  to  do  so  a  few  daj's  after 
birth,  and  if  the  vomiting  has  become  more  forcible  and  projectile 
in  character,  and  continues  in  spite  of  all  regulation  of  diet  and  other 
measures  to  stop  it,  and  if  no  other  symptoms  of  gastric  derangement 
are  present,  we  should  certainly  be  inclined  to  consider  the  case  pyloric 
stenosis.  A  careful  physical  examination  of  the  abdomen  should  be 
made  shortly  after  feeding,  and,  after  the  epigastrium  has  been  closely 
scrutinized  for  the  peristaltic  wave,  an  endeavor  made  to  palpate  the 
tumor  at  the  pylorus.  If  the  peristaltic  wave  be  seen  and  the  tumor 
found,  the  diagnosis  is  amply  confirmed. 

Indigestion  accompanied  by  vomiting  is  easily  excluded  if  other 
symptoms  of  indigestion  are  absent  and  by  the  facts  that  the  infant 
is  being  breast  fed  and  there  is  no  cause  for  an}'  derangement  of  diges- 
tion. Emaciation  is  much  more  rapid  in  hypertrophic  pyloric  stenosis, 
and  there  is  neither  foul  breath,  coated  tongue,  anorexia,  nor  diarrhea 
such  as  is  found  in  gastric  indigestion.  Simple  pylorospasm  presents 
most  of  the  symptoms  of  hypertrophic  pyloric  stenosis,  and  in  some 
instances  it  is  impossible  to  differentiate  these  two  conditions  posi- 
tively. 

In  a  typical  case  of  hypertrophic  stenosis,  however,  a  differentiation 
can  be  made  with  reasonable  certainty.  Constipation  is  much  more 
marked  in  stenosis  than  in  spasm;  the  baby  is  usually  breast  fed  in 
a  case  of  stenosis  and  artificially  fed  in  pylorospasm;  moreover,  if 
the  tumor  on  palpation  does  not  vary  in  size  and  shape,  the  evidence 
is  almost  conclusively  in  favor  of  hypertrophic  stenosis.  Dilatation 
of  the  stomach  is  strongly  suggestive  of  hypertrophic  stenosis,  and 
failure  to  improve  under  proper  treatment  is  reasonable  evidence  of 
an  organic  lesion.  Habitual  vomiting  of  infancy  may  be  mistaken  for 
hypertrophic  pyloric  stenosis;  but  in  habitual  vomiting  of  infancy 
there  is  no  constipation  or  loss  of  weight,  and  the  baby  continues  to 
thrive,  whereas  in  hypertrophic  pyloric  stenosis  it  fails  rapidly. 

Prognosis. — The  prognosis  in  hypertrophic  pyloric  stenosis  depends 
upon  the  extent  of  the  hypertrophy  and  the  physical  condition  of 
the  child  when  brought  under  observation.  If  there  is  a  considerable 
degree  of  hypertrophy,  medical  treatment  affords  no  hope  of  recovery; 
and  if  it  seems  likely  that  the  child  will  survive  the  shock  of  an  opera- 
tion pyloroplasty  or  posterior  gastro-enterostomy  should  be  performed, 
and  will  be  followed  by  recovery  in  a  large  majority  of  cases,  if  done 
by  a  skilful  surgeon.  If  but  a  slight  degree  of  hypertrophy  is  present, 
there  may  be  great  improvement  after  proper  medical  treatment. 

Treatment. — From  many  points  of  view,  surgical  treatment  of 
hypertrophic  pyloric  stenosis  is  far  preferable  to  miedical  attention. 
Extensive  hypertrophy  at  the  pylorus  demands  immediate  operation 
as  the  only  chance  for  recovery.  With  a  moderate  degree,  the  patient 
improves  but  little  under  medical  treatment,  and  it  is  doubtful  whether 
even  a  very  slight  hypertrophy  of  the  pylorus  is  benefited  at  all. 

Unless  the  obstruction,  however  insignificant,  be  removed,  there 


308  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

remains  a  potential  factor  for  benign  obstruction  of  the  pylorus  in 
later  years.  In  some  cases  the  pylorus  may  be  dilated  by  means  of 
forceps  introduced  into  the  stomach;  but  the  best  results  follow  pyloro- 
plasty and  posterior  gastro-enterostomy.  Before  operation  the  stom^ 
ach  should  be  washed  out  and  salt  solution  given  by  rectum  for 
absorption.  Enteroclysis  may  be  continued  after  operation,  or  the 
saline  may  be  given  subcutaneously  in  an  emergency. 

As  soon  as  postanesthetic  nausea  has  subsided  the  child  may  be 
put  to  the  breast;  but  only  a  dram  or  two  of  milk  should  be  allowed 
at  a  time,  and  this  should  be  followed  by  a  half  ounce  of  water  after 
each  nursing.  The  breast  is  allowed  every  hour,  however,  until  the 
amount  at  each  feeding  can  be  increased,  after  which  normal  feeding 
is  gradually  resumed. 

If  operation  is  contra-indicated,  the  feedings  are  reduced  and 
gradually  again  increased,  just  as  in  the  postoperative  cases,  and  the 
stomach  is  washed  out  daily.  If  spasm  of  the  pylorus  is  complicating 
a  mild  degree  of  hypertrophy,  it  is  sometimes  possible  to  feed  these 
infants  by  catheter.  Bicarbonate  of  soda  in  2-  to  5-grain  doses, 
three  times  a  day,  acts  very  well.  If  a  sedative  is  required,  5  drops 
of  paregoric  may  be  given.  When  alL means  of  introducing  food  into 
the  stomach  fail,  an  effort  must  be  made  to  keep  up  the  nutrition  of 
the  infant  by  means  of  nutrient  enemata. 

PYLORIC   STENOSIS   IN   OLDER   CHILDREN. 

It  is  not  my  intention  to  study  here  the  condition  spoken  of  as 
congenital  pyloric  stenosis  in  infants,  but  to  consider  stenosis  of  the 
pylorus  in  children  who  have  passed  the  period  of  infancy.  The  study 
of  the  condition  in  older  children  must,  however,  embrace  those 
patients  in  whom  the  condition  has  persisted  from  infancy  into  later 
childhood,  as  well  as  those  cases  in  which  infancy  has  been  free  from 
all  symptoms  of  pyloric  stenosis,  but  in  which  the  symptoms  appeared 
months  or  years  later. 

At  the  outset  of  this  study  one  is  immediately  impressed  by  the 
fact  that  while  medical  literature  is  crowded  with  articles  on  con- 
genital hypertrophic  pyloric  stenosis  and  pyloric  spasm  in  infants, 
there  has  been,  as  far  as  I  am  aware,  little  written  exclusively  on  the 
condition  in  older  children. 

The  discussion  in  all  of  these  papers  deals  with  the  problem  as  to 
whether  the  condition  is  congenital  or  not;  as  to  the  cause  of  the 
hypertrophy  of  the  circular  muscular  fibers  at  the  pylorus;  as  to 
whether  in  a  given  case  the  condition  is  one  of  pyloric  spasm  simply, 
or  h\T)ertrophic  stenosis  simply,  or  both  spasm  and  hypertrophy,  and 
as  to  the  necessity  for  an  operation. 

The  etiology  of  these  congenital  or  early  cases  of  pyloric  stenosis 
has  been  considered  as  due,  perhaps,  to  gastric  hyperacidity,  or  at 
least  to  some  disturbance  of  gastric  secretion  and  consequent  gastric 
indigestion.     Other  causes  are  hyperplasia  at  the  pylorus,  edema  of 


PYLORIC  STENOSIS  IN  OLDER  CHILDREN  309 

the  mucous  membrane  of  the  pylorus  and  pyloric  spasm.  The  causes 
of  spasm  are  not  clear.  It  may  be  due  to  a  toxemia,  to  gastric  dilata- 
tion, to  a  change  in  the  gastric  secretion,  or  it  may  be  nervous  in 
origin.  The  classical  symptoms  are  vomiting,  constipation,  progres- 
sive loss  in  weight,  scanty  urine,  visible  peristaltic  waves,  and  possibly 
the  finding  of  a  tumor  at  the  pylorus. 

The  treatment  ordinarily  advised  is  feeding,  stomach%ashing, 
opium,  poultices  to  the  epigastrium,  saline  enemata  for  the  purpose 
of  absorption  of  liquid,  nutrient  enemata,  operation. 

A  study  of  the  subject  of  organic  pyloric  stenosis  as  found  in  Ameri- 
can, English,  German  and  French  literature  has  impressed  forcibly 
on  me  the  belief  that  a  careful  clinical  examination  of  children  and 
young  adults  will  result  in  bringing  to  light  a  fair  proportion  of  cases 
of  organic  stenosis  during  this  period  of  life.  The  condition  was  long 
overlooked  in  infants;  and  while  not  flattering  to  clinicians,  it  is,  I 
believe,  nevertheless  true  that  the  condition  is  now  being  overlooked 
in  the  older  child  and  young  adult. 

Children  and  young  adults^  who  present  gastric  symptoms  that 
continue  for  months  or  years,  and  especially  if  vomiting  and  epigastric 
pain  are  present,  may  be  suffering  from  organic  pyloric  stenosis,  and 
if  such  patients  have' been  treated  for  a  long  time  medicinally  without 
behefit,  the  probability  of  there  being  organic  pyloric  stenosis  increases. 
Many  such  cases  have  finally  come  to  operation,  and  a  pyloric  stenosis 
found  by  the  surgeon  at  operation. 

The  reason  why  medical  treatment  failed  in  these  patients  is  then 
clear.  Permanent  changes  have  taken  place  in  the  gastric  secretory 
apparatus  as  the  result  of  the  long  continuance  of  the  hypertrophic 
stenosis,  and  a  cure  by  medical  treatment  is  impossible.  An  early 
recognition  of  the  pyloric  obstruction  should  in  a  fair,  or  probably  in 
a  large,  proportion  of  these  cases  lead  to  their  cure  by  medical  rather 
than  surgical  treatment.  This  seems  at  least  probable,  if  one  is  to 
reason  by  the  results  obtained  in  pyloric  stenosis  in  infants  and  older 
children.  A  study  of  the  cases  in  infants  and  older  children  treated 
medically  shows  conclusively  that  the  majority  of  those  infants  who 
suffer  from  a  mild  degree  of  hypertrophic  pyloric  stenosis  are  cured 
by  the  physician  and  do  not  come  to  operation.  Heubner-  reports 
19  cured  in  21  infants;  Bendix,^  30  in  32  cases;  Hutchinson,'*  13  in 
14  cases.    Stark,^  11  out  of  12  cases;  Bloch,'^  6  patients,  all  recovered. 

I  do  not  wish  to  be  understood  as  implying  that  there  are  not 
patients  who  require  operation.  I  believe  that  the  position  taken 
on  the  question  of  operation  by  Robert  Hutchinson,^  "that  operation 
is  never  in  any  circumstances  justified  in  these  cases,"  is  an  extreme 
one,  but  that  most  of  the  cases  of  slight  and  moderate  pyloric  stenosis 
can  be  cured  by  medical  treatment  is  my  firm  belief. 

1  Maylard,  British  Med.  Jour.,  July  11,  1908,  p.  71. 

2  Therap.  d.  Gegenw.,  1906,  vol.  viii.  3  ^gd.  Klin.,  1909,  vi,  1813. 

4  Clin.  Jour.,  September  9,  1908.  s  Zentralbl.  f.  Kinderh.,  1909,  xiv,  .5. 

sjahrb.  f.  Kinderh.,  1907,  Ixv,  317.  '  Loc.  cit. 


310  DISEASES  OF   THE  GASTEO-INTESTIXAL   TRACT 

It  is  an  acccptctl  fact  that  many  patients  live  into  a(h'anee(l  adult 
life  wlio  at  autopsy  show  congenital  pyloric  stenosis.  Iludolph  ]\Iayer^ 
reports  31  such  cases.  Cautley  and  Dent-  report  3  cases  of  pyloric 
stenosis  at  the  age  of  six,  eleven  and  twenty-two  years,  respectively, 
and  believe  they  were  probably  congenital.  ]Mayo  Robson  reports 
1  case,  Lauderer^  10  and  William  RusselP  3  cases. 

There  is  probably  no  doubt  that  congenital  pyloric  stenosis  of  a 
mild  grade  may  remain  latent  for  months  and  probably  for  years,  and 
cases  of  organic  pyloric  stenosis  have  been  observed  during  the  second 
and  third  j^ears  of  life,  where  a  distinct  insufficiency  of  motility, 
together  with  hyperacidity  existed.  There  is  probably  hardly  any 
year  between  early  infancy  and  well-advanced  old  age  that  does  not 
show  cases  of  pyloric  stenosis  in  which  the  patients  have  come  to 
operation.  Some  of  these  patients  have  had  gastric  symptoms  from 
childhood;  in  others  the  symptoms  vary  from  a  few  months  to  a 
number  of  years.  Rosenlieim^  reports  a  case  in  a  child  who  had 
always  enjoyed  good  health  until  an  attack  of  measles  at  the  age  of 
five  years,  from  which  he  made  a  good  recovery.  Three  months  later 
the  child  began  to  vomit  and  contmued  to  vomit  almost  every  day. 
When  six  and  a  half  years  of  age  he  was  operated  on  and  found  to  be 
suffering  from  h\'pertrophic  pyloric  stenosis.  The  case  ended  in 
recovery.  Osier  reports  a  case  of  hypertrophic  pyloric  stenosis  "in 
a  child  that  lived  until  the  third  year. 

There  is  much  room  for  thought  in  the  study  of  the  cases  in  which 
the  hypertrophic  stenosis  is  not  sufficient  in  amount  to  produce 
dangerous  symptoms  in  infancy.  The  hypertrophy  gradually  increases 
in  degree,  the  stenosis  becomes  more  marked,  and  in  later  years  the 
child  presents  the  symptoms  directly  and  indirectly  produced  by 
the  stenosed  pylorus.  Beardsley  reports  a  case  at  the  age  of  fom* 
years,  Sonnenberg  one  at  five  years,  and  Hansy  one  at  eleven  years 
(Cautley^). 

Then  there  are  cases  that  present  exactly  the  opposite  pictiue.  The 
symptoms  of  hypertrophic  pyloric  stenosis  are  very  severe  in  infancy; 
the  babies  are  so  ill  that  it  seems  as  if  they  must  surely  die.  They 
recover,  however,  and  at  the  age  of  three  or  fom*  years  are  apparently 
perfectly  well.    Robert  Hutchinson  has  reported  such  cases. 

The  question  naturally  arises,  what  has  occurred  in  these  cases? 
Has  the  congenital  hypertrophy  of  the  pylorus  largely  or  partly  disap- 
peared? Has  the  compensatory  hypertrophy  of  the  stomach  muscles 
been  sufficient  to  overcome  the  original  condition,  and  has  no  gastric 
dilatation  occurred,  or  has  it  been  a  combination  of  both  conditions? 
Cases  are  reported  m  which  apparently  no  gastric  dilatation  has 
occurred,  and  the  evidence  in  such  cases  points  strongly  to  absorption 
of  the  hypertrophy. 

1  Virchow's  Arch.  f.  Path.  Anat.,  1885,  cii,  413. 

2  Tr.  Roy.  Med.  and  Chir.  Soc,  1902,  lxxx\d. 

3  Tubingen,  1879.  4  British  Med.  Jour.,  July  11,  1908. 
5  Berl.  klin.  Wehnschr.,  1899,  xxxii,  703.  «  Diseases  of  Children,  1910,  p.  264. 


PYLORIC  STENOSIS  IN  OLDER  CHILDREN  311 

What  is  the  exphiiiation  of  the  very  hiroe  percentage  of  recoveries 
reported  by  certain  observers — Ileubiier,  Bendix,  Hutchinson,  Stark, 
and  Bloch?  I  believe  it  is  as  follows :  Many  of  these  cases  are  instances 
of  pyloric  spasm;  others  are  cases  of  slight  hypertrophic  pyloric  steno- 
sis; ni  still  others,  both  spasm  and  a  mild  degree  of  hypertrophy  exist, 
and  if  one  is  ready  to  admit  that  a  slight  amount  of  hypertrophic 
pyloric  stenosis  may  be  largely  or  in  part  absorbed,  the  explanation 
is  quite  satisfactory.  Stiles,  who  has  operated  on  many  of  these 
patients,  claims  that  true  congenital  hypertrophic  stenosis  of  the 
pylorus  is  rare,  and,  when  it  does  occur,  should  be  treated  surgically. 
Cautley  is  of  about  the  same  opinion,  but  believes  that  very  mild 
cases  of  this  disease  may  recover  under  medical  treatment.  Cases 
of  this  character  may,  and  probably  do,  m  some  instances,  show 
gastric  symptoms  and  evidence  of  pyloric  stenosis  in  later  life,  since 
persistent  stenosis  in  the  older  child  is  represented  by,  first,  a  period 
of  compensatory  stomachic  muscular  h^-pertrophy ;  this  is  followed 
by  a  period  which  may  exist  from  the  inception  of  the  stenosis  which 
represents  stagnation  and  the  slow  emptying  of  the  stomachic  con- 
tents; and  lastly,  retention,  or  the  failure  of  the  stomach  ever  to 
completely  empty  itself.  Is  it  not  possible  to  recognize  these  cases 
clinically?    Should  they  come  to  operation  undiagnosed? 

The  following  conclusions  in  regard  to  h}T)ertrophic  pyloric  stenosis 
in  older  children  and  young  adults  seem  to  me  to  be  justifiable: 

1.  Pyloric  .stenosis  is  present  in  children  and  young  adults  more 
commonly  than  is  supposed. 

2.  The  age  at  which  it  manifests  itself  depends  on  the  degree  of 
stenosis  present. 

3.  Pyloric  stenosis  may  be  latent  for  years. 

4.  It  is  found  by  the  surgeon  during  childhood  and  young  adult 
life,  and  its  early  recognition  by  the  physician  is  important  from  the 
standpoint  of  early  medical  or,  if  necessary,  surgical  treatment. 

5.  The  enthe  disappearance  of  all  the  classical  symptoms  of  con- 
genital hypertrophic  stenosis,  and  the  apparent  health  of  the  infant 
during  its  subsequent  early  childhood,  suggest  the  probability  of  an 
absorption  of  the  hypertrophy,  especially  as  no  gastric  dilatation 
may  develop  later  in  life. 

The  stomach  through  the  sympathetic  and  cerebrospinal  nerves  is 
connected  with  practically  all  organs  and  tissues  in  the  human  body, 
and  it  has  been  demonstrated  that  pyloric  spasm  can  be  produced 
artificially  by  stimulation  of  the  vagus.  The  contraction  of  involun- 
tary muscular  tissue,  the  source  of  the  contraction  being  outside  the 
stomach,  is  at  least  probable. 

Is  pyloric  spasm  unassociated  with  pain  and  with  persistent  vomit- 
ing, a  common  condition,  or  even  an  occasional  condition  in  older 
children?  It  certainly  clinically  does  not  resemble  the  cases  described 
as  associated  with  gastric   ulcer,^  and   gall-stone  colic  in  which  the 

1  Fairchilds,  Iowa  Med.  Jour.,  Des  Moines,  1910-11,  xvii,  212. 


312  DISEASES  OF   THE  GASTRO-IXTESTIKAL   TRACT 

pain  is  excessive  and  \-()miting  not  a  marked  symptom.  Periodic 
pyloric  spasm  ma}'  occur  at  the  menstrual  period/  unassociated  with 
any  disease  of  the  stomach,  or  with  spasm  in  any  other  portion  of  the 
body,  and  under  such  conditions  is  probably  a  primary  spasm  of  the 
pylorus,  a  motor  neurosis.  Lauder  Brunton's  obser\'ations  tend  to 
show  that  pyloric  spasm  may  accompany  migraine,  and  be  a  manifes- 
tation of  a  neurosis. 

A  number  of  cases  of  infantile  pyloric  spasm  have  been  followed 
up  to  the  age  of  five  years  and  older,  and  found  to  be  in  first-class 
health,  and  in  quite  a  considerable  number  of  such  cases  there  is  no 
neurotic  family  history.  The  clinician  should  not  lose  interest  in 
these  babies  after  they  pass  beyond  the  period  of  infancy,  and  an 
effort  should  be  made  to  follow  their  subsequent  histories,  especially 
with  reference  to  any  gastric  symptoms. 

Cases  of  infantile  pyloric  spasm  have  been  kept  under  observation 
for  years.-  All  the  symptoms  may  persist  until  the  third  year,  and 
the  child  may  remain  nervous  and  anemic  for  years  afterward.  In 
other  cases,  solid  food  can  not  be  given  until  the  child  is  three,  or 
even  five  years  old.  In  still  other  cases  of  spasm,  vomiting  may 
persist  until  the  patient  is  four  years  old  or  older,  and  the  peristaltic 
waves  may  continue  until  the  child  is  over  four  years  of  age. 

Cases  diagnosed  as  cyclic  ^'omiting  have  come  to  autopsy^  and  the 
lumen  of  the  pylorus  has  been  found  to  be  very  small,  with  a  distinct 
hypertrophy.  In  these  cases  the  children  may  be  four  or  five  years  of 
age,  the  s\Tnptoms  of  epigastric  pain  and  vomiting  having  been 
present  sirce  birth,  returning  at  irregular  intervals  of  months,  and  the 
children  being  apparently  perfectly  well  between  the  attacks. 

I  do  not  mean  to  give  the  impression  that  cyclic  vomiting  and  pyloric 
spasm  are  not  two  entirely  dift'erent  conditions,  but  to  suggest  the 
advisability  of  considering  the  possibility  of  pyloric  spasm  producing 
symptoms  that  resemble  closely  those  of  cyclic  vomiting. 

^^'hat  are  the  causes  of  the  pylorospasm  in  infancy  that  disappears 
in  later  childhood?  Half  of  these  children  are  breast-fed,  and  it  seems 
to  me  unnatural  to  claim,  as  does  von  Starck,  that  the  unaccustomed 
presence  of  food  in  the  stomach  produces  an  irritation  of  the  gastric 
mucosa  and  so  causes  the  spasm. 

A  clearer  understanding  of  the  etiology  in  infants  may  help  us  in 
the  recognition  and  study  of  the  condition  in  older  children. 

•  ENTERALGIA    OR   COLIC. 

Colic  is  paroxysmal  pain  caused  by  a  spasm  of  the  intestinal  muscles; 
and,  although  merely  a  symptom  of  gastro-intestinal  disorder,  it  is 
so  common  in  infancy  and  early  childhood  that  it  merits  special  con- 
sideration.    Artificially  fed  babies  suffer  much  more  from  colic  than 

'  Hemmeter,  Diseases  of  the  Stomach,  Ed.  3,  p.  744. 

2  Heubner,  Berlin,  Therap.  d.  Gegenw.,  1906,  viii,  43.3. 

sProe.  Roy  Soe.  Med.,  London,  1909-10,  iii.  Sect.  Dis.  Child.,  78. 


ENTERALGIA  OR  COLIC  313 

do  the  breast-fed,  but  it  is  by  no  means  infrequent  when  the  feeding 
is  apparently  ideal. 

The  most  common  cause  of  colic  is  gas  in  the  stomach  and  intestines, 
which  accumulates  rapidly  as  a  result  of  fermentation  due  to  indiges- 
tion and  improper  feeding,  especially  when  there  is  intolerance  to 
sugar,  or  when  the  carbohydrate  or  protein  content  of  the  food  is 
excessive.  In  many  instances,  air  swallowed  while  nursing  from 
the  breast  or  bottle  is  also  responsible  for  intestinal  pain  after 
feeding. 

Colic  may  occasionally  be  a  symptom  of  far  more  serious  import 
than  in  the  cases  mentioned,  since  it  is  present  in  appendicitis,  obstruc- 
tion of  the  bowel,  peritonitis,  and  intussusception.  It  may  also  be 
caused  by  intestinal  parasites,  by  chilling  of  the  abdomen,  and  by 
drinking  ice-water. 

Symptoms. — The  symptoms  of  colic  need  but  little  description. 
The  child  cries  out  in  pain;  its  face  is  distorted,  its  legs  are  drawn 
up;  the  knees  and  elbows  are  bent,  and  the  hands  clinched.  The 
abdomen  is  hard  and  tense,  but  there  is  no  tenderness,  and  the  press- 
ure of  the  warm  hand  in  palpating  brings  relief.  There  is  no  fever; 
but  the  child  may  break  into  cold  sweat  during  a  paroxysm  and  turn 
pale,  its  extremities  grow  cold,  and  it  may  go  into  collapse. 

These  symptoms  usually  appear  shortly  after  the  child  is  fed,  caus- 
ing it  to  moan  and  cry  until  there  is  an  eructation  of  gas  from  the 
stomach  and  discharge  of  flatus  from  the  bowel,  after  which  the  pain 
disappears  and  relief  is  evident.  The  pain  may  sometimes  be  miti- 
gated by  giving  the  infant  some  food  as  soon  as  it  begins,  but  usually 
it  returns  in  a  short  time.  In  carbohydrate  indigestion  colic  does  not 
set  in  until  several  hoiu"s  after  the  first  or  second  feeding. 

Diagnosis. — Simple  colic  will  need  to  be  differentiated  from  appen- 
dicitis, otitis  media,  and  intussusception.  The  localized  tenderness 
and  rising  fever  which  accompany  appendicitis  usually  reveal  the 
source  of  pain  in  that  disease.  In  intussusception,  there  is  early  tumor 
formation,  and  the  bowels  are  constipated,  the  discharges  containing 
blood  and  mucus.  If  acute  otitis  media  be  present,  and  the  child  be 
watched  closely,  it  will  usually  indicate  in  some  way  that  the  supposed 
colicky  pain  in  the  abdomen  is  really  in  the  ear.  Peritonitis  may  also 
be  excluded  by  the  severity  of  the  vomiting  and  the  short  duration 
of  the  pain. 

Treatment. — The  most  effectual  treatment  of  colic  is  to  relieve  the 
distention  of  the  intestines  by  promoting  the  expulsion  of  the  gas, 
and  to  prevent  further  fermentation  and  gas  formation  by  careful 
regulation  of  the  diet.  The  child  or  infant  should  lie  on  its  belly  and 
hot-water  bags  or  hot  poultices  may  be  applied.  An  enema  of  warm 
water  almost  always  brings  relief,  and  warm  peppermint-water  should 
be  administered  by  mouth. 

If  the  peppermint  does  not  relieve  the  pain,  we  should  not  resort 
to  alcohol  or  opiates,  but  the  infant  may  be  given  a  drop  or  two  of 
Hoffman's  anodyne,  1  or  2  grains  of  bicarbonate  of  soda,  15  drops  of 


314  DTSEASES  OF   THE  GASTRO-TXTESTIXAL   TRACTy 

elixir  of  anise,  or  5-  to  lO-drop  closes  ol'  Wyeth's  elLxir  of  catnip  and 
fennel.  It  is  sometimes  well  to  give  a  teaspoonful  of  castor  oil  or  a 
tablespoonful  of  milk  of  magnesia  to  children  who  habitually  suffer 
from  colic;  and  if,  during  the  nursing  period,  they  are  taken  from 
the  breast  and  held  upright,  at  the  same  time  being  patted  on  the 
back,  the  gas  will  escape  and  the  tendency  to  attacks  of  colic  be 
greatly  lessened.  If  the  intervals  between  feedings  are  lengthened, 
and  the  amount  of  food  is  decreased  for  a  short  time,  these  attacks 
usually  cease.  The  strength  and  quantity  of  the  food  may  then 
be  gradually  increased  until  the  child  is  taking  ample  nourishment. 
Strict  attention  should  be  paid  to  the  clothing  these  children  wear, 
in  order  to  guard  against  any  chilling  of  the  abdomen,  and  to  make 
sure  that  there  are  no  constricting  bands  around  the  waist. 

HEMATEMESIS. 

Hematemesis  is  not  an  uncommon  occurrence  in  childhood,  though 
infrequent  during  mfancy.  True  hematemesis  may  be  due  to  the 
hemorrhagic  diseases  which  aflfect  the  newborn,  to  gastric  ulcer,  also 
to  scurvv,  purpura,  hemophilia,  vicarious  menstruation,  acute  leuke- 
mia, and  splenomegaly,  as  well  as  to  accidental  causes.  In  some 
cases  the  blood  is  swallowed  and  then  ejected  from  the  stomach, 
thus  simulatmg  the  hematemesis  seen  m  breast-fed  infants  when  the 
blood  from  cracked  and  fissured  nipples  is  swallowed  with  the  milk 
and  then  vomited. 

It  also  occurs  in  children  who  swallow  blood  from  the  nose,  gums, 
or  throat.  Blood  which  is  immediately  ejected  as  soon  as  it  enters 
the  stomach  is  apt  to  be  of  a  bright  scarlet  color;  but  it  is  dark 
and  coffee-colored  if  it  has  remained  there  for  any  length  of  time. 
When  passed  by  the  bowel,  blood  always  makes  the  stools  black  and 
tarry. 

Treatment. — If  the  blood  actually  comes  from  the  stomach  the  case 
is  one  of  true  hematemesis,  and  the  child  should  be  put  to  bed  and 
deprived  of  food  and  liquids  until  the  bleeding  stops.  Calcium  lactate 
may  be  given  in  5-gram  doses,  tln-ee  times  a  day,  or  adrenaline 
chloride  in  1  to  1000  solution  in  o-drop  doses,  three  times  a  day. 

An  injection  of  fresh  human  blood  serum  is  by  far  the  most  effectual 
measure  to  stop  the  bleeding,  and  as  much  as  an  ounce  may  be  given  to 
an  infant,  three  times  a  day,  with  no  danger  of  untoward  effects.  Smaller 
amounts  often  fail  to  control  the  hemorrhage;  therefore,  if  it  be 
obtainable,  the  maximum  dose  should  be  given.  Horse  serum,  diph- 
theria antitoxin  or  coagulose  may  be  used  instead  of  fresh  human 
blood  serum.  Coagulose  is  supplied  in  15  c.c.  glass  bulbs  which  con- 
tain 0.65  gram  of  desiccated  powder,  equivalent  to  10  c.c.  of  human 
blood  serum.  Coagulose  will  keep  for  a  long  time  without  losing  any 
of  its  properties. 


GASTRIC   ULCER  315 

GASTRIC  ULCER. 

Ulceration  of  the  stomach  is  very  rare  before  adult  life,  but  during 
childhood  is  more  frequently  observed  in  infants  than  in  older  chil- 
dren. There  may  be  but  one  small  perforating  ulcer  or  many  areas 
of  shallow  ulceration  which  is  hardly  more  than  erosion.  Follicular 
ulcers  caused  b\'  acute  gastritis  are  more  common  in  infancy  and 
childhood  than  in  adult  life.  Tuberculous  ulcers  are  exceedingly  rare, 
yet  they  occur  either  as  one  large  ulcerated  area  or  several  smaller 
ones.  Acute  ulceration  of  the  stomach  shows  a  distinct  tendency  to 
perforation,  and  usually  appears  at  the  cardia,  wliile  the  chronic 
gastric  ulcer  which  results  in  scar  formation  and  cicatrical  contraction 
is  generally  located  near  the  pylorus. 

Etiology. — ^When  a  newborn  infant  suddenly  develops  a  gastric 
ulcer,  many  good  reasons  incline  us  to  believe  it  either  of  embolic  origin 
or  due  to  some  other  circulatory  change,  such  as  venous  stagnation 
or  ecchymosis.  In  older  children  the  same  etiological  factors  are  active 
which  are  potent  in  adult  life.  In  some  cases  chronic  ulceration  of  the 
stomach  and  gastric  erosions  are  thought  to  be  secondary  to  catarrhal 
gastritis,  while  gastric  ulcer  is  observed  in  association  with  the  hemor- 
rhagic diseases  of  the  newborn,  with  scorbutus,  and  with  septicemia, 
and  occasionally  follows  one  of  the  acute  infectious  diseases.  Con- 
genital ulceration  of  the  stomach  has  been  reported. 

Symptoms. — During  infancy  and  childhood  vomiting  of  blood  and 
the  passage  of  bloody  stools  are  the  only  characteristic  symptoms  of 
gastric  ulcer,  and  in  the  absence  of  these  a  diagnosis  is  impossible,  inas- 
much as  the  additional  signs  and  symptoms  are  simply  those  of  gas- 
tritis. The  pain  may  be  mistaken  for  colic  since,  as  a  rule,  it  imme- 
diately follows  the  ingestion  of  food  and  causes  vomiting;  but  if  the 
amount  of  blood  in  the  vomitus  be  small,  as  is  frequently  the  case  in 
follicular  ulceration,  it  escapes  notice  and  the  true  condition  is  not 
suspected.  Blood  vomited  soon  after  a  hemorrhage  is  scarlet-red, 
and  practically  unchanged;  if  it  has  been  retained  for  any  length  of 
time  in  the  stomach  it  is  coffee  colored,  and  when  passed  in  the  stools 
very  dark  and  tarry.  When  a  gastric  ulcer  is  present,  hemorrhage  is 
often  induced  by  active  exercise  or  a  heavy  meal,  and  if  the  amount  of 
blood  lost  is  small,  frequent  hemorrhages,  while  unnoticed,  may  cause 
secondary  anemia  which  develops  rapidly  and  may  be  one  of  the  first 
marked  symptoms.  The  epigastrium  is  usually  tender  on  palpation, 
although  the  pain  may  be  referred  to  the  back.  Frequently  there  is 
an  associated  catarrhal  gastritis.  The  bowels  may  be  either  loose  or 
constipated. 

Diagnosis. — In  children  the  diagnosis  of  gastric  ulcer  can  frequently 
be  made  if  there  is  vomiting  of  blood  and  melena,  but  when  there  is 
little  or  no  hemorrhage  the  disease  is  recognizable  only  at  postmortem. 

Prognosis. — The  prognosis  is  often  unfavorable,  since  death  usually 
follows  hemorrhage  or  perforation.  In  the  absence  of  these  compli- 
cations, and  when  the  ulcer  is  situated  at  the  cardia  or  the  pylorus, 


316  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

cicatrization  may  ensue  and  cause  stenosis  and  dilatation  of  the 
stomach. 

Treatment. — If  gastric  ulcer  be  suspected  and  the  child  is  vomiting 
blood,  it  should  be  put  to  bed  and  kept  there  until  all  symptoms  have 
subsided.  Food  and  drink  by  mouth  should  be  withheld,  and  nourish- 
ment given  by  rectum  in  the  form  of  nutrient  enemata.  When  thirst 
is  extreme  pieces  of  ice  may  be  given  the  child  to  suck,  and  small  sips 
of  water  allowed.  As  improvement  sets  in,  weak  broths  should  be 
added  to  the  diet,  and  the  quantity  and  strength  of  the  food  gradually 
increased  until  the  norrhal  diet  is  established.  Bleeding  may  be  so 
severe  that  the  child  will  sink  into  collapse  and  die  before  any  measures 
to  control  it  can  be  taken.  If  stimulation  is  required,  camphorated 
oil,  administered  in  one  to  five  doses  hypodermically,  or  black  coffee, 
2  to  6  drams,  with  20  to  80  drops  of  brandy,  injected  into  the  rectum, 
will  frequently  be  of  service.  Gelatin  in  dram  doses,  given  by  mouth 
every  hour,  has  controlled  bleeding  in  not  a  few  cases. 

Although  drugs  are  usually  ineffectual,  adrenalin  chloride  solution, 
1  to  1000,  in  1-  to  3-drop  doses  every  hour,  or  bismuth  subnitrate, 
in  lO-grain  doses  every  three  hours,  may  be  tried.  The  injection  of 
human  serum,  one  ounce  of  which  may  be  used  subcutaneously  in  an 
infant,  will  often  be  followed  by  cessation  of  bleeding.  Excepting  sur- 
gery this  is,  perhaps,  the  most  reliable  method  of  checking  internal 
hemorrhage.  Injections  of  one  to  three  ounces  of  human  blood,  the 
blood  being  withdrawn  from  the  donor  by  means  of  a  sterile  syringe 
and  immediately  injected  into  the  patient,  have  a  decided  influence 
in  controlling  hemorrhage.  If  human  serum  or  whole  blood  cannot 
be  quickly  obtained,  horse  serum,  or  diphtheria  antitoxin  which  con- 
tains horse  serum,  can  usually  soon  be  secured  and  injected.  The 
results  from  these  injections  are  often  most  satisfactory. 

Pain  is  sometimes  so  severe  as  to  require  the  hypodermic  adminis- 
tration of  morphine,  or  the  rectal  injection  of  chloral,  bromides,  or 
paregoric,  which  should  be  given  in  double  the  dosage  prescribed  by 
mouth.  Hot  fomentations  are  also  of  service  in  relieving  epigastric 
pain;  but  if  there  is  hemorrhage,  cold  applications  are  indicated.  Per- 
foration of  the  stomach  demands  immediate  surgical  intervention; 
but  the  mortality  rate  from  such  operations  is  very  high,  even  though 
a  competent  surgeon  operate  immediately  on  a  case  in  which  perfora- 
tion has  been  diagnosed. 

CHRONIC  INTESTINAL  INDIGESTION. 

Chronic  intestinal  indigestion  is  usually  associated  with  chronic 
gastric  indigestion,  and  occurs,  as  a  rule,  in  children  who  have  had 
repeated  acute  attacks  of  indigestion. 

Etiology. — It  is  most  common  during  infancy,  and  may  be  either 
congenital  or  acquired.  The  congenital  form  is  due  to  an  inherent 
weakness  of  the  intestinal  digestive  power,  while  the  acquired  type  is 
usually  brought  on  by  a  prolonged  period  of  injudicious  feeding.    Chil- 


CHRONIC  INTESTINAL  INDIGESTION  317 

dren  whose  health  is  undermined  by  syphihs,  tuberculosis,  rachitis, 
or  other  chronic  disease,  are  especially  liable  to  it,  and  it  may  follow 
a  severe  attack  of  scarlet  or  typhoid  fever,  diphtheria,  or  other  acute 
infection.  In  the  majority  of  cases,  chronic  intestinal  indigestion  is 
observed  in  the  children  of  the  poor  who  are  segregated  amid  unhy- 
gienic surroundings,  and  who  do  not  receive  proper  care  or  food.  The 
breast-fed  baby  rarely  suffers. unless  the  mother  is  extremely  careless 
and  the  infant  is  nursed  without  regard  to  regularity,  but  the  con- 
dition is  very  common  in  bottle-fed  babies,  and  constitutes  one  of  the 
most  difficult  affections  which  the  practitioner  is  called  upon  to  treat 
in  infancy  and  childhood. 

Perhaps  the  most  common  source  of  trouble  in  artificial  feeding  is 
the  faulty  composition  of  the  feeding  mixture  which  results  in  either 
fat,  carbohydrate,  or  protein  indigestion..  Overfeeding  is  another 
frequent  cause  of  trouble,  due  to  the  mother's  habit  of  giving  the  baby 
the  bottle  whenever  it  cries  to  quiet  it.  Whether  the  food  be  too  rich 
in  one  or  all  constituents,  or  too  great  a  quantity  be  given,  the  result 
is  an  overtaxing  of  the  intestinal  digestion  which,  if  greatly  prolonged, 
weakens  the  digestive  function  and  produces  a  state  of  chronic 
indigestion. 

While  chronic  digestive  disturbances  are  especially  common  during 
the  first  year  of  infancy,  intestinal  indigestion  is  not  uncommon  in 
older  children.  Here  the  usual  cause  is  an  excess  of  carbohydrates 
from  overindulgence  in  cakes,  candies,  pastries,  and  other  rich  and  indi- 
gestible foods.  In  some  cases  the  condition  arises  because  the  child  is 
fed  for  a  year  or  two  after  weaning  on  too  large  a  proportion  of  cereals, 
bread,  and  potatoes.  Condensed  milk  and  patent  foods  are  often  the 
cause  of  infantile  indigestion,  for  they  are  rarely  prepared  properly, 
and,  although  the  child's  stomach  usually  tolerates  them  for  a  short 
time,  their  continued  use  sets  up  digestive  disturbances  which  are  hard 
to  correct.  Regularity  in  feeding  is  just  as  important  with  older  chil- 
dren as  with  infants,  and  the  habit  of  eating  between  meals,  which  is 
so  common  during  childhood,  often  gives  rise  to  chronic  intestinal 
indigestion,  because  of  the  continuous  strain  upon  the  digestion. 

Pathology. — As  a  rule  there  are  no  clearly  defined  pathological  lesions 
of  the  intestines,  since  this  condition  is  usually  a  functional  disturb- 
ance, therefore  is  not  accompanied  by  organic  changes.  In  protracted 
cases,  evidences  of  a  low-grade  catarrhal  inflammation  of  the  intestinal 
mucosa  may  be  found,  and,  in  addition,  the  lymphoid  tissue  of  the 
intestines  and  mesenteric  glands  may  be  enlarged  and  swollen. 

Symptoms. — There  is  usually  a  history  of  injudicious  feeding  or  other 
dietetic  error,  as  a  result  of  which  the  infant  has  repeatedly  had  acute 
attacks  of  gastro-enteritis.  Partial  recovery  has  followed,  and  then 
the  series  of  acute  attacks  has  yielded  to  a  state  of  chronic  and  persis- 
tent indigestion.  The  weight  at  first  remains  stationary,  then  begins 
to  fall,  and  other  signs  of  impaired  nutrition,  such  as  anemia,  subnormal 
temperature,  failing  circulation,  irritability,  restlessness  and  disturbed 
sleep,  develop.     The  bowels  are  usually  loose,  diarrhea  alternating 


318  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

with  occasional  and  irregular  periods  of  constipation.  The  stools 
are  usually  a  greenish  color,  and  composed  of  undigested  food,  as  is 
shown  by  the  presence  of  fat  and  protein  curds. 

In  some  cases  they  are  extremely  watery,  highly  acid,  and  frothy,  and 
are  passed  with  much  flatus,  which  indicates  a  disturbance  of  carbo- 
hydrate digestion.  There  is  generally  a  moderate  amount  of  mucus 
in  the  stool  in  the  form  of  shreds  which  may  surround  the  fecal  masses. 
The  stools  average  five  or  six  daily,  but  during  acute  exacerbations 
the  infant  may  have  from  twelve  to  twenty  a  day.  Although  constipa- 
tion usually  alternates  with  diarrhea  in  intestinal  indigestion,  yet  now 
and  then  the  constipation  stubbornly  persists,  and  in  these  cases  the 
stools  are  hard,  dry,  covered  with  mucus,  and  may  be  passed  with 
extreme  difficulty. 

Intestinal  colic  and  flatulence  are  much  more  distressing  in  the  cases 
that  are  constipated  than  in  those  wdth  diarrhea,  and  fever  is  more 
likel}^  to  be  present.  Vomiting  occurs  only  occasionally,  and  is  never  a 
constant  feature  of  the  disease.  The  appetite  may  be  good  or  impaired, 
but  is  usually  capricious;  the  tongue  is  always  coated;  the  breath 
has  a  fetid  odor.  In  both  infants  and  children  the  abdomen  is  dis- 
tended, protuberant,  and  tympanitic;  but,  as  a  rule,  there  is  little  or  no 
tenderness.  The  skin  is  usually  dry,  the  extremities  are  cold,  the  tem- 
perature is  subnormal  except  during  acute  exacerbations,  and  when 
the  child  is  constipated.  An  infant  may  remain  in  this  condition  almost 
indefinitely,  but  its  development  is  retarded,  both  mentally  and  physi- 
cally, so  that  it  may  be  two  or  three  years  of  age  before  it  can  walk  or 
talk. 

In  the  older  child  the  symptoms  of  chronic  intestinal  indigestion  are 
somewhat  different  from  those  in  infants.  Constipation  is  present 
instead  of  diarrhea;  but  in  exceptional  cases  the  bowels  may  be  loose. 
The  stools  are  hard,  either  gray  or  white  and  of  foul  odor.  Colic  is 
sometimes  severe,  and  there  is  usually  much  flatulence.  The  appetite 
may  be  good  or  poor,  but  is  usually  either  impaired  or  so  capricious 
as  to  fail  to  provide  sufficient  nourishment.  In  consequence  these 
children  become  thin,  pale,  and  anemic,  with  dry  skin,  sunken  eyes, 
and  cold  extremities.  They  are  usually  listless  and  apathetic,  show 
no  desire  to  play,  and  are  easily  fatigued.  The  nervous  system  is  some- 
times markedly  affected,  causing  the  child  to  be  extremely  irritable  and 
cross.  In  some  cases  attacks  of  syncope  and  dizziness  are  quite  com- 
mon. Convulsions  are  rare;  but  acute  attacks  of  vomiting  with  severe 
headache  are  not  infrequent. 

The  absorption  of  toxins  from  the  intestine  produces  a  mild  but  con- 
tinuous fever  with  occasional  sharp  rises  in  temperature  when  the  tox- 
emia becomes  more  profound.  The  urine  is  high  colored,  concentrated, 
and,  as  the  result  of  intestinal  stupor,  contains  an  excess  of  indican. 
In  older  children  the  skin  frequently  shows  evidence  of  urticaria  or 
other  lesion  due  to  the  gastro-intestinal  disturbance  while  in  infancy 
ecz,ema  and  intertrigo  on  the  thighs  and  buttocks  are  a  common  result 
of  the  irritating  action  of  the  stools, 


CHRONIC  INTESTINAL  INDIGESTION  319 

Diagnosis. — In  the  majority  of  cases  the  diagnosis  of  chronic  intes- 
tinal indigestion  is  easily  made  if  the  symptoms  and  history  of  con- 
tinued digestive  derangement  are  taken  into  consideration;  but  in 
order  to  treat  the  condition  successfully  its  exact  nature  must  be 
ascertained.  The  character  of  the  stools  will  be  a  clue  to  the  form  of 
indigestion  present,  and  a  microscopic  examination  of  the  feces  will 
determine  whether  there  is  intolerance  to  fat,  proteins,  or  carbo- 
hydrates. In  fat  indigestion  the  bowels  are  loose,  semisolid,  of  a 
yellowish-green  color,  and  contain  fat  curds.  Carbohydrate  indigestion 
is  indicated  by  very  loose  or  watery  and  highly  acid  movements,  which 
irritate  the  buttocks  and  are  passed  with  much  flatus.  If  the  bowels 
are  constipated,  the  infant  is  usually  suffering  from  protein  indigestion, 
and  large  casein  curds  are  found  in  the  stools.  Colic  is  apt  to  be  more 
severe  in  this  form  of  indigestion,  and  there  is  more  or  less  vomiting. 
In  some  cases  tuberculosis  may  be  suspected,  but  examination  of  the 
lungs  is  negative,  there  is  no  cough,  and  the  temperature  range  is 
unlike  that  of  tubercular  infection. 

Prognosis. — The  prognosis  depends  upon  the  vitality  of  the  child, 
the  duration  of  the  disease,  and,  to  a  certain  extent,  upon  the  mode 
of  treatment  and  the  thoroughness  with  w^hich  it  is  carried  out.  As 
a  rule,  the  outlook  is  more  favorable  in  breast-fed  infants  and  in  older 
children;  but,  at  the  best,  improvement  is  very  slow  and  recovery  gradual. 

Treatment. — The  most  important  phase  of  treatment  is  the  regula- 
tion of  the  diet.  When  the  infant  is  breast-fed,  if  the  stools  show  an 
excess  of  fat,  which  indicates  that  the  milk  is  too  rich,  the  time  the  baby 
is  allowed  to  nurse  should  be  shortened,  and  an  ounce  or  tw^o  of  water 
given  the  child  in  addition  to  each  nursing  to  dilute  the  mother's 
milk.  The  diet  of  the  mother  may  also  be  restricted.  The  baby  should 
be  nursed  at  regular  intervals  of  not  less  than  three  hours.  In  excep- 
tional cases  it  may  be  necessary  to  pump  the  milk  from  the  mother's 
breasts  and  skim  it  before  giving  it  to  the  child;  but  under  no  cir- 
cumstances should  any  other  food  be  substituted  for  the  milk  of  the 
mother  unless  a  suitable  wet-nurse  be  found.  If  the  child  is  bottle- 
fed,  and  a  wet-nurse  can  be  procured,  the  giving  of  human  milk  forms 
an  easy  solution  of  the  dietetic  problem. 

In  every  case  it  is  advisable  at  the  beginning  of  treatment  to  withhold 
all  milk  for  a  day  or  two,  and  then,  if  it  be  necessary  to  give  a  feeding 
mixture,  the  formula  should  contain  a  very  low  percentage  of  fats 
and  proteins.  The  amount  of  fats,  carbohydrates,  or  proteins  to  be 
given  an  infant  should  always  depend  upon  the  character  of  the  stools ; 
and  if  intolerance  to  any  one  of  these  constituents  is  evident  the  amount 
of  that  one  ingredient  to  be  put  into  the  feeding  mixture  should  be 
decreased  until  iinprovement  in  digestion  is  noted. 

As  a  rule,  it  is  well  to  give  a  fat-free  mixture  at  the  onset  of  treatment 
to  babies  who  are  exclusively  bottle-fed,  and  to  stop  all  starchy  food 
in  children  two  or  three  years  old  who  are  on  a  mixed  diet.  Bottle- 
fed  babies  should  be  given  dextrinized  gruels  and  cereals,  fat-free  milk 
that  has  been  peptonized,  fat-free  whey,  and  albumen-water  in  small 


320  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

quantities  at  frequent  intervals  as  a  substitute  for  the  milk  mixture. 
As  the  child  improves  fat  may  be  very  slowly  added,  I  to  |  per  cent,  at 
a  time,  and  the  percentage  of  sugar  also  increased  as  the  digestive 
power  of  the  patient  improves. 

A  strong  tendency  pre^'ails  to  substitute  patent  infant  foods  when 
milk  is  not  borne  well;  but  in  these  cases  they  are  apt  to  do  harm  and, 
as  a  rule,  it  is  wiser  to  resort  to  Eiweiss  milk,  broths,  buttermilk,  or 
malt  soup  formulas.  In  older  infants  broths,  beef  juice,  scraped  meat, 
fruit  juices,  and  a  little  dry  bread,  or  a  few  crackers  may  be  given; 
but  all  starchy  foods  should  be  much  restricted  for  at  least  a  year. 
Children  who  have  been  allowed  to  eat  between  meals  and  indulge 
in  sweets  and  pastries  should  be  kept  upon  a  very  plain  but  nutritious 
diet  for  a  month  or  two,  and  allowed  to  eat  only  at  meal  time.  The 
child  of  two  years  may  be  fed  five  meals  daily,  the  child  of  three  or 
four  should  eat  four  times  a  day,  and  at  five  years  three  meals  are 
sufficient.  As  a  rule,  cakes,  candies,  pastries,  potatoes,  hot  bread, 
fried  food,  and  raw  fruits  should  be  prohibited  in  the  dietary  of  children 
with  weak  digestion;  but  beef,  lamb,  chicken,  fish,  eggs,  and  rice  are 
usually  well  digested. 

The  medicinal  treatment  of  chronic  intestinal  indigestion  should 
consist  of  an  initial  purgative  dose  of  castor  oil,  repeated  at  intervals 
during  the  course  of  the  disease,  and  the  bowels  kept  open  by  the  use 
of  a  mild  laxative  to  insure  at  least  one  passage  a  day.  In  the  cases 
with  diarrhea  it  is  well  to  administer  bismuth  subnitrate  in  5-  to  10- 
grain  doses,  also  tincture  of  nux  vomica  in  one-  to  three-drop  doses 
for  its  tonic  effect  on  the  system.  The  s\Tup  of  the  iodide  of  iron  is 
also  of  service  during  convalescence,  given  in  full  tonic  doses  of  10  to 
30  drops,  according  to  the  age  of  the  child.  Intestinal  irrigations  are  to 
be  resorted  to  only  during  acute  exacerbations ;  for,  if  too  long  continued, 
they  are  liable  to  irritate  the  colon  and  do  more  harm  than  good. 

The  general  treatment  of  these  children  should  be  carefully  carried 
out.  The  clothing  must  be  warm  enough  to  protect  the  child  from 
changes  in  temperature.  An  abdominal  binder  gives  support  to  the 
distended  abdomen,  and  should  be  worn  continuously.  The  impor- 
-  tance  of  the  daily  bath  should  be  emphasized,  and  a  cold  sponge  each 
morning  is  most  beneficial  unless  the  child  is  too  weak  for  it,  as  shown 
by  coldness  or  blueness  of  the  extremities  after  the  brisk  rubbing 
which  should  always  follow  a  cold  sponge. 

If  sent  to  the  mountains  or  seashore,  children  improve  rapidly;  but 
when  such  change  of  environment  is  impossible,  abundance  of  fresh 
air  should  be  given  the  child  by  keeping  it  out  of  doors  during  pleasant 
weather  and  having  the  sleeping  room  well  ventilated  at  night. 

CHRONIC   ILEOCOLITIS. 

Chronic  ileocolitis  is  induced  either  by  severe  attacks  of  acute  ileo- 
colitis or  by  chronic  intestinal  indigestion;  but  the  most  severe  cases 
are  those  which  follow  acute  ileocolitis. 


CHRONIC  ILEOCOLITIS  321 

Etiology. — An  acute  attack  of  ileocolitis  usually  becomes  chronic 
because  of  poor  management  of  the  diet  and  lack  of  hygienic  care.  In 
a  few  instances  it  may  follow  typhoid  fever,  pneumonia,  and  other 
acute  infectious  diseases,  especially  scarlet  fever  and  measles.  After 
severe  and  protracted  cases  of  chronic  intestinal  indigestion,  we  find 
at  postmortem  chronic  inflammation  of  the  ileum  and  colon,  which  is 
the  result  of  constant  irritation  of  the  intestinal  mucosa  by  bacterial 
toxins,  fermentation,  and  the  products  of  decomposition. 

Pathology. — The  most  common  pathological  lesions  found  in  the 
intestines  are  a  change  in  color  to  dull  gray;  slight  pigmentation; 
swelling  of  the  lymphoid  tissue;  and  a  thickening  of  the  mucosa  of 
the  ileum  and  colon.  In  addition  to  these  evidences  of  chronic  catarrhal 
inflammation  of  the  mucosa,  there  are  hemorrhagic  and  ecchymotic 
areas  scattered  throughout  the  walls  of  the  bowels,  while  an  excessive 
secretion  of  mucus  covers  the  mucosa.  In  severe  and  protracted  cases, 
a  section  of  the  intestinal  wall  studied  under  the  microscope  will  show 
the  tubular  glands  of  the  mucosa  to  be  atrophied,  and  the  villi  and 
follicles  undergoing  degenerative  changes.  The  mesenteric  glands  are 
swollen  and  enlarged,  and  occasionally  show  caseation  in  the  centre. 
Ulceration  is  rare  in  chronic  ileocolitis;  but  at  postmortem  follicular 
ulcers  are  occasionally  found,  and  less  frequently  large  superficial 
ulcers. 

Bronchopneumonia  and  hypostatic  congestion  of  the  lungs  are  the 
most  frequent  accompanying  diseases.  In  severe  cases  there  is  cloudy 
swelling  of  the  heart  muscle,  also  fatty  degeneration  of  the  liver  cells. 
Nephritis  is  rare;  but  in  most  cases  the  renal  epithelium  is  found  in  a 
state  of  cloudy  swelling. 

Symptoms. — In  the  majority  of  cases  the  most  important  symptoms 
of  chronic  ileocolitis  are  constant  diarrhea  and  progressive  emacia- 
tion. The  stools  are  usually  yellowish  green  or  brown  in  color,  and 
number  three  to  six  a  day.  They  consist  of  undigested  food  and  mucus, 
but  there  is  rarely  any  blood  except  in  ulcerative  cases.  The  abdomen 
is  generally  distended  and  tympanitic ;  and  there  may  or  may  not  be 
a  great  amount  of  colic  and  flatulence.  Tenesmus  is  not  as  severe, 
nor  prolapse  of  the  rectum  as  common,  as  in  acute  ileocolitis. 

In  many  cases  the  appetite  is  unaffected  and  the  child  rarely  vomits ; 
but  emaciation  is  continuous  and  progressive,  and  the  face  acquires 
a  wizened  and  pinched  expression.  The  skin  is  dry  and  coarse,  and 
may  be  eczematous  about  the  anus  and  genitalia.  The  constitutional 
symptoms  become  aggravated  as  the  disease  progresses,  and  in 
advanced  cases  the  eyes  are  sunken,  the  fontanelle  is  depressed,  the 
temperature  subnormal,  the  heart  beat  weak  and  rapid.  The  child 
becomes  so  exhausted  that  it  rarely  moves,  and  the  cry  is  merely 
a  whine.  The  feet  and  hands  are  cold  because  of  the  poor  circulation, 
and  the  extremities  may  become  edematous.  At  the  onset  of  the  disease 
the  child  is  fretful,  cross,  and  irritable,  perhaps  crying  continually, 
and  throughout  the  attack  it  is  nervous  and  peevish.  The  nervous 
symptoms  are  varied,  delirium  and  stupor  being  common,  but  con- 
21 


322  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

viilsions  are  rare.  Death  usually  supervenes  as  the  result  of  some 
complication  or  intercurrent  disease,  such  as  bronchopneumonia,  or 
one  of  the  exanthemata. 

Diagnosis. — Chronic  ileocolitis  may  simulate  general  tuberculosis,  and 
the  child  should  be  thoroughly  examined  with  the  view  of  excluding 
this  disease  as  an  underlying  factor.  Absence  of  fever  and  of  demon- 
strable foci  in  the  lungs  and  a  negative  von  Pirquet  reaction  will  usually 
preclude  the  possibility  of  tubercular  infection.  Syphilis  should  be 
excluded  by  careful  inquiry  into  the  history  of  the  mother  and  by  blood 
examination  if  necessary.  Rachitis  presents  such  characteristic  physi- 
cal signs  that  its  presence  is  perfectly  obvious.  It  is  practically  impos- 
sible to  form  any  idea  of  the  extent  of  the  ulceration,  but  the  catarrhal 
form  of  chronic  ileocolitis  may  be  diagnosed  by  the  absence  of  blood 
in  the  stools  and  the  comparatively  mild  character  of  the  disease. 

Prognosis. — The  prognosis  in  the  severe  cases  is,  as  a  rule,  unfavor- 
able, and  is  rendered  still  more  so  by  existing  systemic  diseases  or  by 
the  poor  environment  so  often  observed  in  this  disease.  The  outcome 
also  depends  upon  the  vitality  of  the  child  when  brought  under  obser- 
vation, its  age,  and  the  severity  of  the  attack.  Infants  may  die,  but 
the  chances  of  recovery  are  much  more  favorable  in  older  children. 

Treatment. — AYhenever  possible  these  children  should  be  removed 
from  their  unliygienic  surroundings  and  sent  to  the  country  or  sea- 
shore; or,  at  least,  should  be  given  the  advantage  of  plenty  of  fresh 
air,  for  improvement  is  much  more  rapid  when  the  child  lives  under 
sanitary  conditions.  Much  depends  upon  the  thoroughness  with  which 
treatment  is  instituted;  hence  it  is  important  that  the  mother  of  the 
child  carry  out  orders  implicitly  or  that  she  secure  a  reliable  trained 
nurse. 

An  initial  purgative  dose  of  castor  oil  should  be  given,  and  there- 
after the  bowels  should,  be  moved  every  day ;  milk  of  magnesia  may  be 
given  to  infants,  and  cascara  sagrada  to  older  children.  Colonic  irri- 
gations should  only  be  used  diu-ing  the  acute  exacerbations;  for,  if 
employed  continuously,  they  may  irritate  the  rectum  and  colon  and 
cause  an  increased  secretion  of  mucus  by  aggravating  the  inflamed 
mucosa.  When  by  absorption  an  accumulation  of  fecal  matter  gives 
rise  to  autointoxication,  the  colon  should  be  irrigated  with  normal 
saline  solution,  after  which  several  ounces  of  a  2  per  cent,  tannic  acid 
solution  should  be  injected  and  allowed  to  remain  for  fifteeen  to  twenty 
minutes. 

Regulation  of  the  diet  is  perhaps  the  most  important  part  of  treat- 
ment. The  feeding  should  be  carefully  supervised  throughout  the 
attack  and  for  months  after  recovery  has  taken  place,  because  indiscre- 
tions in  diet  cause  relapses,  one  of  which  may  prove  fatal.  ^Mother's 
milk  should  be  given  whenever  possible.  If  the  baby  is  bottle-fed,  milk 
should  be  withheld  for  several  days,  and  albumen-water,  dextrinized 
cereals,  or  w'eak  broths  substituted.  After  improvement  sets  in  pep- 
tonized milk,  Eiweiss  milk,  malted  soups,  or  buttermilk  may  be  tried 
in  lieu  of  ordinarv  milk. 


INT  USS  use  EFT  ION 


'A-ri 


When  it  seems  wise  to  give  milk,  a  weak  formula  containing  2  per 
cent,  of  fats,  4  per  cent,  of  sugar,  and  1  per  cent,  of  protein  should  be 
used  for  the  infant  of  six  months,  and  weaker  formulas  for  \'ounger 
babies.  These  mixtures  may  gradually  be  made  stronger  as  the  diges- 
tive power  of  the  infant  increases.  An  arrest  of  the  progressive  loss 
of  weight  is  a  favorable  indication,  and  a  steady  gain  in  weight  may  be 
regarded  as  a  sign  of  ultimate  recovery,  provided  there  are  no  relapses. 

INTUSSUSCEPTION. 

Intussusception  is  the  slipping  of  one  portion  of  the  intestine  into 
another,  and  is  one  of  the  causes  of  acute  obstruction  of  the  bowels. 
The  most  common  site  for  this  affection  is  the  ileocecal  region,  although 
it  may  occur  in  any  part  of  the  intestinal  tract.  There  are  three  ana- 
tomical forms :  the  enteric,  in  which  one  portion  of  the  small  intestine 
is  invaginated  into  another  section  of  the  small  bowel;  the  colic,  in 
which  the  large  bowel  is  invaginated  within  the  large  bowel;  and  the 
ileocecal,  caused  by  the  invagination  of  the  ileum  and  cecum  into  the 
colon. 

Etiology. — Intussusception  is  a  rare  disease,  but  occurs  much  more 
frequently  in  childhood  and  infancy  than  in  adult  life.  The  majority 
of  cases  are  seen  in  children  less  than  a  year  old,  and  males  babies  are 
affected  more  frequently  than  females.  Its  exact  cause  is  unknown. 
Several  theories  have  been  advanced,  the  most  probable  of  which  are 
based  upon  the  irregular  muscular  action  (spasmodic  in  character) 
of  the  intestinal  wall  and  paresis  of  the  muscular  coats  of  the  bowel. 
In  a  certain  number  of  cases  Meckel's  diverticulum  and  other  abnor- 
malities have  been  found,  and  exceptionally  there  is  a  history  of  ante- 
cedent digestive  disturbance  and  inflammation  of  the  bowels.  Ty- 
phoid fever  may  also  be  followed  by  intussusception ;  here  the  weakened 
condition  of  the  intestines  is  probably  a  factor  in  its  causation.  In 
most  cases,  however,  the  patient  is  a  healthy  and  well-noursished  infant 
who  has  never  been  ill;  therefore  the  disease  is  caused  more  frequentl}^ 
by  overactive  and  spasmodic  intestinal  movements  than  by  lack  of 
muscular  tone.  A  history  of  abdominal  injury  is  occasionally  elicited; 
but  the  relation  between  trauma  and  intussusception  has  not  been 
established. 

Pathology. — Invagination  takes  place  from  above  downward,  hence 
the  distal  portion  of  the  affected  intestine  is  found  drawn  over  the  proxi- 
mal end.  At  the  site  of  the  lesion  we  find  three  layers  of  bowel:  the 
outer,  or  intussuscipiens,  which  receives  the  invaginated  portion;  the 
internal,  or  entering  layer;  and  the  returning  layer.  These  last  two 
layers  are  invaginated  and  enclosed  by  the  first,  and  are  known  as  the 
intussusceptum.  The  intussusceptum  is  thickened  and  congested, 
and  in  the  course  of  a  few  days  adhesions  form  between  this  and  the 
enclosing  layer  of  intestine.  Obstruction  of  the  bowel  is  the  result  of 
congestion  and  edema,  and  the  blood  supply  is  cut  off  by  traction  on 
the  mesentery  which,  if  unrelieved,  causes  gangrene  and  sloughing.    At 


324         DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

postmortem  there  is  frequently  found  a  condition  known  as  agonal 
intussusception,  in  which  multiple  intussusceptions  have  taken  place 
throughout  the  intestinal  canal. 

Symptoms. — In  the  usual  form  of  the  disease  the  symptoms  develop 
suddenly,  and  are  so  severe  that  they  may  cause  shock  and  collapse. 
Vomiting  is  persistent  and  violent,  and  occurs  earliest  in  the  attack 
when  the  lesion  is  high  up  in  the  small  bowel.  Pain  is  severe  and  comes 
in  paroxysms,  during  which  the  child  lies  on  its  back  with  the  thighs 
drawn  up  on  the  abdomen.  There  are  no  prodromes ;  therefore  healthy 
children  are  sometimes  attacked  while  nursing  or  asleep,  and  may  be 
quickly  prostrated  or  go  into  collapse.  The  bowel  discharges  are  loose 
and  evacuated  with  much  tenesmus.  After  the  fecal  matter  below 
the  site  of  the  obstruction  has  been  discharged,  the  stools  are  composed 
of  blood  and  mucus. 

The  temperature  becomes  subnormal;  the  face  is  pale;  the  pulse  is 
rapid  and  feeble.  Pain  subsides  when  gangrene  sets  in,  but  vomiting 
continues,  although  it  is  not  as  a  rule  stercoraceous.  The  bowels 
usually  become  absolutely  constipated  about  the  third  or  fourth 
day. 

The  abdomen,  at  first,  is  neither  tender  nor  distended,  but  so  relaxed 
that  abdominal  palpation  is  easily  accomplished.  During  the  first 
day  or  two  the  presence  of  a  tumor  is  readily  ascertained  but,  later  on, 
the  abdomen  becomes  distended  and  tympanitic,  and,  if  peritonitis 
develop,  is  tender  and  rigid  throughout. 

In  a  considerable  proportion  of  the  cases  a  tumor  may  be  detected 
by  digital  examination  through  the  rectum,  and  it  should  always  be 
sought  for,  since  it  is  a  valuable  aid  to  diagnosis.  The  mass  is  sausage- 
shaped,  from  four  to  six  inches  long,  and  of  putty-like  consistency. 
It  is  rendered  more  prominent  by  abdominal  examination  or  by  an 
attack  of  severe  pain.  It  may  be  located  in  any  part  of  the  intestinal 
tract,  and  is  sometimes  found  projecting  from  the  anus. 

Intussusception  generally  runs  an  acute  course.  If  the  obstruction 
is  not"  relieved  prostration  becomes  extreme,  the  temperature  ascends 
because  of  the  toxemia  and  peritonitis,  the  child's  face  assumes  an 
anxious  expression,  and  it  finally  dies  in  collapse. 

Diagnosis. — The  diagnosis  of  intussusception  can  be  made  with  cer- 
tainty in  any  case  where  there  is  a  history  of  sudden  severe  pain, 
vomiting,  and  bloody  stools,  and  when  a  tumor  can  be  felt  along  the 
intestinal  tract.  The  sudden  onset,  the  violence  of  the  symptoms,  the 
absence  of  fever,  the  shock,  sharply  differentiate  this  disease  from  ileo- 
colitis, gastro-enteritis,  or  other  intestinal  inflammation. 

Prognosis. — During  infancy  an  attack  of  intussusception  runs  a  rapid 
course;  and,  in  the  majority  of  cases,  unless  relieved  spontaneously 
or  by  operation,  will  terminate  in  death  within  five  days.  The  earlier 
the  operation  and  the  older  the  child  the  better  the  outcome.  Sub- 
acute and  chronic  cases  offer  a  more  favorable  outlook  than  do  those  of 
the  acute  type,  in  which  the  chances  of  recovery  are  reduced  consider- 
ably by  each  succeeding  day  of  the  disease, 


Fig.  30. — Drawing  of  specimen  from  a  case  of  intussusception  in  an  infant.  In 
the  diagram  the  letters  have  the  same  signification.  A  A,  colon;  B,  point  where  the 
ileum  enters  the  intussusception.  The  letter  B  points  directly  within  the  intestinal 
lumen.  A  probe  passes  in  at  B  and  comes  out  at  C.  The  diagram  illustrates  the  course 
which  it  must  pursue.  D  is  the  appendix;  E,  point  of  constriction  of  the  ileum;  F, 
point  of  slight. eversion  where  the  serous  coat  turns  to  pass  within  the  bowel;  G  shows 
the  line  of  constriction  in  the  ileum  caused  by  the  ileocecal  valve.  The  specimen  has 
been  pulled  through  the  valve  to  show  this  line  of  constriction  and  the  gangrenous 
mass  of  intestine  beyond  extending  from  G  to  C.  This  point  of  constriction  in  the 
diagram  is  indicated  by  a  slight  depression  at  G.  H,  I  and  J  show  the  line  of  attach- 
ment of  the  mesentery.  Between  H  and  I,  and  extending  slightly  beyond  the  line  /, 
is  a  fold  produced  by  pulling  the  intestine  through  the  ileocecal  valve  sufficiently  far 
to  show  the  gangrenous  process. 


326  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

Treatment. — Surgical  iiitcr\'eiitit)U  should  iuiincdiately  follow  the 
making  of  a  diagnosis;  for,  if  the  gut  is  not  gangrenous,  the  condition 
may  easily  be  corrected  by  a  laparotomy.  Attempts  at  reduction  by 
other  measures  are  justifiable,  but  should  not  delay  operation.  Warm 
water  may  be  injected  into  the  colon,  and,  if  no  force  is  used,  will  do 
no  harm.  Inflation  of  the  intestines  by  air  under  pressure  is  a  danger- 
ous procedm-e,  and,  if  employed,  the  air  should  be  introduced  very 
slowly.  The  child  should  be  inverted  when  these  methods  of  reduction 
are  being  tried.  If,  perchance,  reduction  is  accomplished,  no  food 
should  be  allowed  for  from  twelve  to  tw^enty-four  hours,  the  bowels 
should  be  kept  quiet  by  suitable  doses  of  paregoric,  and  no  cathar- 
tics or  pm"gati^'es  given  for  at  least  a  week. 

CHRONIC   CONSTIPATION. 

Chronic  constipation,  which  is  quite  common  in  infancy  and  child- 
hood, is  characterized  by  a  failure  of  the  bowels  to  move  regularly, 
and  by  stools  which  are  smaller  than  normal,  very  dry,  and  passed 
with  much  difficulty.  An  infant  whose  bowels  are  regular  should  have 
two  or  three  movements  daily,  and  the  older  child  at  least  one  stool 
a  day. 

Etiology. — Constipation  in  the  breast-fed  infant  is  usually  due  either 
to  a  deficiency  in  the  quantity  of  food  or  a  deficiency  of  fat  in  the  breast 
milk.  These  two  factors  must  also  be  considered  in  the  constipation  of 
artificially  fed  babies;  in  addition  there  may  be  in  the  milk  formula  an 
excess  of  protein  which,  in  itself,  will  result  in  hard,  dry  stools.  Infants 
are  all  predisposed  to  constipation  because  of  the  position  of  the  intes- 
tines diu-ing  infanc}^;  for  situated,  as  they  are,  mainly  in  the  pelvis, 
the  great  length  of  the  large  intestine  in  proportion  to  the  size  of  the 
child's  pelvis  results  in  multiple  flexures  which  retard  to  a  great  extent 
the  movement  of  the  fecal  contents,  and  favor  the  absorption  of  the 
liquid  portion  of  the  stool,  making  the  mass  hard  and  dry. 

Atony  of  the  intestines  is  a  frequent  cause  of  constipation  in  children 
who  suffer  from  rachitis,  malnutrition,  anemia,  tuberculosis,  or  any 
other  chronic  disease.  In  the  acute  infections,  owing  to  the  reduction 
in  body  fluid  caused  by  fever,  the  stools  are  often  hard  and  dry.  Occa- 
sionally a  steady  milk  diet  will  constipate,  especially  if  no  water  is 
given,  and  in  older  children  a  diet  lacking  in  residue,  as  would  be  the 
case  if  vegetables  and  fruits  were  restricted  or  omitted,  will  tend  to 
produce  constipation.  In  rare  cases  constipation  will  prove  to  be  due 
to  an  organic  cause,  such  as  stricture  of  the  anus,  imperforate  anus, 
anal  fissure,  proctitis,  or  hemorrhoids.  In  some  families  there  undoubt- 
edly exists  a  hereditary  predisposition  to  defective  musculature  of  the 
bowels,  which  manifests  itself  early  in  life  by  stubborn  chronic  consti- 
pation in  the  child. 

Symptoms. — The  most  common  indication  of  constipation  is  a  diminu- 
tion in  the  normal  number  of  bowel  movements;  but  in  some  cases, 
while  the  number  of  stools  is  normal,  they  are  very  hard,  dry,  and 


CHRONIC  CONSTIPATION  327 

smaller  than  they  slioulfl  l)f,  iiidicatint;-  tliat  the  waste  pnxhiets  of  the 
intestines  are  not  all  bein<;'  exeretecl.  In  constipation,  evacnation  (jf 
the  bowels  is  usually  attended  by  much  pain  and  straining  wdiich  may 
lead  to  inflammation  of  the  rectum  and  the  passage  of  blood  and  mucus 
in  the  stools.  If,  for  an  unusual  length  of  time,  the  bowels  are  insuffi- 
ciently evacuated,  constitutional  symptoms  appear  and  the  child 
becomes  restless,  feverish,  nervous,  and  irritable,  and  may  complain 
of  persistent  abdominal  pain.  The  tongue  is  heavily  coated,  the  breath 
foul,  and  all  desire  for  food  is  lost. 

Diagnosis. — Constipation  in  itself  is  but  a  symptom  the  underlying 
cause  of  which  should  be  sought,  and  the  diagnosis  of  this  primary 
condition  is  sometimes  extremely  difficult. 

Prognisis. — The  prognosis  of  chronic  constipation  depends  largely 
upon  the  cause;  as  a  rule,  it  is  very  resistant  to  treatment  and  difficult 
to  correct. 

Treatment. — The  most  important  point  in  the  treatment  of  chronic 
constipation  is  to  ascertain  the  cause  and  remove  it.  If  there  is  mus- 
cular atony  of  the  intestines,  due  to  constitutional  dyscrasia,  an  effort 
should  be  made  to  build  up  the  child's  general  health  by  careful  regu- 
lation of  the  diet  and  the  administration  of  such  tonics  as  cod-liver 
oil,  or  drop  doses  of  the  tincture  of  nux  vomica ;  in  addition,  special 
attention  should  be  directed  to  the  treatment  of  the  underlying  disease, 
whether  tuberculosis,  syphilis,  or  rachitis.  Inasmuch  as  faulty  diet 
alone  is  responsible  for  many  cases  of  constipation,  the  quantity, 
strength,  and  quality  of  the  food  should  always  be  carefully  investi- 
gated and  adjusted,  although  the  results  obtained  are  not  always  as 
encouraging  as  might  be  expected,  probably  because  of  secondary 
atony  due  to  prolonged  distention  of  the  bow^els. 

In  breast-fed  infants  constipation  is  usually  due  to  insufficient  food 
or  to  a  deficiency  of  fat  in  the  mother's  milk;  therefore  the  nursings 
should  be  supplemented  by  artificial  food  in  carefully  prepared  for- 
mulas or  by  additional  breast  milk  from  a  wet-nurse.  If  the  amount  of 
food  is  insufficient  and  the  milk  is  also  poor  in  regard  to  its  fat  content, 
an  eftort  should  be  made  to  improve  the  quality  by  increasing  the 
amount  of  fat  in  the  mother's  diet.  This,  however,  often  fails  to  raise 
the  fat  content,  so  that  it  may  be  necessary  to  give  a  dram  or  two 
of  cream  before  each  nursing.  In  artificially  fed  babies  who  suffer 
from  constipation  the  formulas  and  mixtures  should  be  analyzed  to 
ascertain  if  the  fat  content  is  not  too  low,  and  to  reduce  the  per- 
centage of  protein  if  in  excess.  A  steady  milk  diet  in  later  infancy, 
supplemented  at  times  by  the  addition  of  oat  meal  gruel,  orange  or 
prune  juice,  or  an  occasional  baked  apple,  will  often  correct  or  prevent 
constipation. 

With  older  children  if  the  food  does  not  leave  enough  residue  to  force 
the  bowels  to  move  regularly,  the  amount  of  fruit  and  vegetables 
should  be  increased.  In  regulating  the  diet  of  constipated  infants 
and  children  so  as  to  secure  the  laxative  action  of  certain  articles  of 
food,  the  mistake  is  too  often  made  of  overdoing  the  matter;  hence 


328  DISEASES  OF  THE  GASTEO-IXTESTIXAL   TRACT 

the  artificially  fed  infant,  in  particular,  is  sometimes  given  as  high  as 
6  per  cent,  of  fat  mixtures  in  order  to  facilitate  bowel  evacuations, 
notwithstanding  the  fact  that  to  raise  the  fat  content  above  4  per  cent, 
will  tend  to  constipate.  The  older  child,  too,  is  stuffed  with  fruits  and 
cereals  which  overtax  the  stomach  and  intestines,  not  only  producing 
obstinate  constipation  but  chronic  gastro-enteritis  as  well.  Too  often 
flatulent  dyspepsia  is  begun  in  infancy  in  consequence  of  the  frequent 
administration  of  cane  sugar  or  oatmeal  for  the  relief  of  constipation 
when  the  judicious  use  of  specially  prepared  carbohydrates,  such  as 
Mellin's  food  or  Horlick's  malted  milk  given  once  or  twice  a  day, 
is  all  that  the  infant  requires  to  insure  regularity  of  the  bowels. 

In  some  children  constipation  is  due  largely  to  a  lack  of  proper  train- 
ing with  regard  to  the  bowels.  As  soon  as  it  can  sit  up,  the  infant  should 
be  placed  upon  the  chamber  each  morning  after  its  first  nursing,  and 
if  this  practice  is  continued  throughout  infancy  and  early  childhood 
a  habit  is  formed  which  will  persist  through  life.  The  school  child 
should  not  be  allowed  to  depart  from  the  house  in  the  morning  until 
an  effort  has  been  made  to  evacuate  the  bowels,  and  schools  should 
be  so  conducted  that  children  have  an  opportunity  of  using  the  toilet 
whenever  necessary,  instead  of  being  compelled  to  suppress  this  desire 
as  is  often  the  case.  ^Yater  may  always  be  given  freely  to  the  consti- 
pated child.  In  the  treatment  of  chronic  constipation,  particularly, 
it  is  very  beneficial  to  take  a  glassful  before  breakfast  and  at  night 
before  retiring. 

The  use  of  enemata  and  suppositories  is  so  liable  to  be  abused  that 
we  frequently  find  in  them  a  cause  of,  rather  than  a  remedy  for  chronic 
constipation,  since  by  habitually  resorting  to  them  the  bowel  becomes 
so  accustomed  to  the  powerful  local  stimulus  produced  that  there  is 
little  or  no  response  to  natural  stimulation  alone.  If  only  occasionally 
employed,  however,  they  are  of  unquestionable  value. in  securing  evac- 
uation of  the  lower  bowel  when  the  purgative  action  of  drugs  is  not 
desirable.  In  infants,  especially,  the  simple  expedient  of  inserting 
a  cone  of  Castile  soap  into  the  rectum  will  cause  the  bowels  to  move, 
but  the  mother  should  not  make  a  practice  of  this,  as  it  may  give  rise 
to  severe  irritation  of  the  rectum  and  anus.  Glycerin  suppositories 
are  far  more  irritating  than  cones  of  soap,  hence  should  only  be  used 
occasionally,  and  suppositories  containing  drugs  are  rarely  of  any  value 
in  infancy  and  childhood. 

Furthermore,  enemata,  while  they  are  always  effectual  in  gilding 
temporary  relief,  should  never  be  used  frequently  or  indiscriminately, 
since  they  have  a  tendency  to  balloon  the  rectum,  also  to  favor  the 
accumulation  of  feces,  and  may  cause  atony  of  the  bowel,  thus  greatly 
aggravating  the  constipation.  If,  however,  the  amount  of  fluid  injected 
is  but  small,  dilatation  of  the  rectum  is  not  likely  to  happen.  For  this 
reason  it  is  advisable  to  inject  an  ounce  of  sweet  oil  or  olive  oil,  or  twice 
that  amount  of  warm  soapy  water,  rather  than  to  wash  out  the  rectum 
and  colon  w^ith  a  half-pint  or  more  of  plain  water  or  saline  solution. 
Greater  activity  on  the  part  of  the  infant  or  child  should  be  encouraged 


CHRONIC  CONSTIPATION  329 

as  a  valuable  adjunct  to  treatment,  and  massage  of  the  abdomen, 
especially  along  the  course  of  the  colon,  is  often  beneficial. 

Constipation  which  is  due  to  a  local  lesion  of  the  anus  or  rectum 
depends  for  its  relief  upon  the  cure  of  that  condition.  If  there  be 
spasmodic  contraction  of  the  anus  with  no  apparent  organic  lesion, 
such  as  fissure  in  ano,  etc.,  sodium  bromide  in  2-grain  doses  or  tinc- 
ture of  belladonna  in  drop  doses  may  be  given  the  infant,  and  warm 
applications  made  locally.  Stricture  of  the  anus  requires  dilatation 
either  by  the  finger  or  by  more  forcible  divulsion,  and  fissure  in  ano 
is  best  treated  by  keeping  the  bowels  loose,  and  anointing  the  lower 
part  of  the  rectum  and  anus  with  unguenti  zinci  oxidi,  unguenti 
hydrargyri,  or  a  simple  boric  acid  ointment. 

Electricity  is  the  least  valuable  of  all  therapeutic  measures  in  the 
treatment  of  constipation,  and  therefore  is  practically  to  b.e  regarded 
as  a  last  resort,  and  of  service  only  in  those  cases  where  constipation 
is  due  solely  to  atony  of  the  intestinal  musculature.  The  galvanic 
current  is  more  effectual  than  the  faradic;  when  employed,  one  elec- 
trode should  be  placed  in  the  rectum  and  the  other  passed  over  the 
colon.  If  it  is  desirable  to  use  the  faradic  current,  one  electrode  may 
be  placed  over  the  spine  and  the  other  passed  with  pressure  over  the 
abdomen  along  the  course  of  the  colon.  While  neither  electricity, 
massage,  nor  hydrotherapy  in  the  form  of  the  cold  morning  bath,  if 
used  alone,  is  effectual  in  the  treatment  of  chronic  constipation,  yet 
the  judicious  combination  of  these  measures  with  an  occasional  enema, 
persevered  in  faithfully  for  several  weeks,  will  in  many  cases  yield 
most  gratifying  results. 

Medicinal  treatment  of  constipation  is  a  rather  unsatisfactory  and 
objectionable  mode  of  correcting  it,  since  drugs  are  of  merely  temporary 
service  at  the  most,  and  if  their  use  is  prolonged  the  bowels  become 
tolerant  to  all  but  massive  doses,  and  it  becomes  impossible  to  secure 
a  movement  by  any  of  the  other  methods  suggested.  If  used  at  all, 
drugs  should  be  given  only  occasionally  during  the  course  of  more 
effectual  methods  of  treating  the  condition,  and  the  physician  should 
aim  gradually  to  lengthen  the  interval  between  doses,  as  well  as  to 
reduce  the  amount  of  the  drug  given.  Now  and  then  a  course  of  calo- 
mel, 1  grain  in  divided  doses,  may  be  given  the  child  of  two  or  three 
years  whose  stools  are  grayish  white.  If  there  is  atony  of  the  muscular 
coat  of  the  bowels,  tincture  of  belladonna  or  tincture  of  nux  vomica 
should  be  administered  in  drop  doses  for  its  stimulating  effect.  Cas- 
cara  sagrada  is,  theoretically,  the  best  medicinal  agent  if  drug  treat- 
ment is  to  be  continued  for  any  length  of  time  since,  in  addition  to  its 
purgative  action,  cascara  has  a  tonic  effect  on  the  bowels.  The  dose 
of  the  fluidextract  is  from  two  to  ten  drops  according  to  the  age  of  the 
child,  and  the  elixir  may  be  given  in  one-half  to  one  teaspoonful  doses. 
Maltine  and  cascara  is  very  widely  and  wisely  used.  Aside  from  being 
an  agreeable  preparation,  this  is  a  valuable  adjunct  to  treatment  if 
administered  properly,  since  it  tones  up  the  whole  system  in  addition 
to  its  laeneficial  action  on  the  bowels.    Rhubarb,  either  in  the  form  of 


330  DISEASES  OF   THE  G ASTRO-INTESTINAL   TRACT 

the  aromatic  syru})  or  tlic  mixture  of  rluiharb  ;iii(l  soda,  is  frequently 
given  to  children,  but  should  be  used  cautiously  since  its  continuous 
administration  may  aggravate  the  constipation.  The  same  advice 
applies  to  the  prescribing  of  senna,  either  in  the  form  of  the  infusion, 
of  which  a  half-ounce  three  times  a  day  is  the  proper  dose  for  a  child 
of  three  years,  or  as  the  syrup,  which  is  administered  in  10-  to  20-drop 
doses. 

If  colic  and  flatulence  are  present  salines  are  indicated,  and  10  to 
30  grains  of  sodium  phosphate  should  be  given  diaily  in  cold  water 
before  the  morning  meal.  This,  however,  should  only  be  continued 
until  the  child's  bowels  move  every  day  after  breakfast,  and  then  the 
dose  should  be  gradually  reduced  until  the  drug  can  be  withheld  alto- 
gether. Olive  oil  in  dram  doses  is  frequently  sufficient  to  cause  an 
evacuation  of  the  bowels  in  the  young  infant,  and  does  not  gripe  as 
does  castor  oil.  Liquid  petrolatum,  liquid  albolene,  and  Russian  min- 
eral oil,  if  pure,  are  also  preferable  to  less  inert  agents,  since  their  action 
is  for  the  most  part  mechanical.  The  dosage  of  any  of  the  mineral  oils 
is  from  15  to  100  drops.  If  given  in  milk  their  presence  is  unsuspected. 
For  bottle-fed  babies,  milk  of  magnesia  is  quite  a  popular  laxative, 
a  teaspoonful  being  added  to  the  feeding  mixture.  In  most  cases  it 
acts  very  well;  but  in  common  with  all  other  drugs  used  for  chronic 
constipation  it  should  be  given  only  temporarily,  and  should  be  dis- 
continued as  soon  as  possible. 

INCONTINENCE   OF   FECES. 

The  age  at  which  a  child  exercises  control  over  the  act  of  defecation 
depends  a  great  deal  upon  the  training  it  receives.  If  no  effort  is  made 
to  form  a  habit,  voluntary  control  of  the  bowels  will  in  most  cases  be 
spontaneously  established  at  about  two  years  of  age ;  but  if,  at  the  third 
or  fourth  month,  the  infant  is  placed  upon  the  chamber  each  morning 
after  feeding,  the  habit  of  having  a  stool  at  that  time  every  day  will 
have  become  fixed  by  the  sixth  month.  Incontinence  of  feces,  there- 
fore, should  not  be  considered  abnormal  before  the  second  year;  but 
after  this  it  is  a  pathological  condition  usually  the  result  of  an  organic 
lesion  elsewhere  in  the  body,  but  occasionally  functional  or  due  to  local 
irritation. 

Etiology. — ^Fecal  incontinence  is  seen  most  frequently  as  the  result 
of  injury  to  the  spinal  cord,  transverse  myelitis,  paraplegia,  and  coma- 
tose conditions;  also  in  cases  of  severe  asthenia  with  marked  adynamic 
nervous  state,  such  as  occurs  in  typhoid  fever,  pneumonia,  or  cholera 
infantum,  and  in  grave  attacks  of  scarlet  fever,  diphtheria,  or  other 
acute  infections.  Except  when  found  in  association  with  the  foregoing 
conditions  it  is  exceedingly  rare,  and  may  not  be  observed  in  the  other- 
wise apparently  healthy  child,  as  is  urinary  incontinence.  Sometimes 
incontinence  of  feces  is  associated  with  enuresis  in  extremely  nervous 
children  who  show  other  signs  of  nervous  instability,  such  as  night 
terrors,  stuttering,  and  habit  spasms;  occasionally  there  is  fecal  incon- 


DIARRHEA  331 

liiiriicc  without  enuresis.  Tlie  stools  are  uhnoi'mai,  but  not  ueees- 
sarily  diarrheal  in  eharaeter,  siuee  the  bowels  may  be  moved  but  once 
daily,  yet  the  movements  have  an  offensive  odor,  are  slimy,  and  some- 
times show  fermentation.  This  condition  is  regarded  as  a  nervous 
affection  of  the  intestines,  probably  in  some  way  related  to  the  mucous 
colitis  of  adult  life. 

Prognosis. — The  prognosis  is  always  good  unless  there  is  associated 
organic  brain  or  cord  lesion  or  mental  deficiency.  As  a  rule,  the  habit 
may  be  stopped  within  a  week.  When  observed  during  the  course 
of  a  severe  acute  illness  it  is  merely  a  transient  sign  of  asthenia,  and 
disappears  promptly  with  recovery  from  the  primary  disease.  As  in 
enuresis,  relapses  are  common,  and  should  be  guarded  against  rigidly. 

Treatment. — ^The  child  with  incontinence  of  feces  should,  first  of 
all,  be  restricted  as  to  diet,  and  all  foods  which  have  a  laxative  action 
on  the  bowels,  such  as  fresh  fruits  and  green  vegetables,  should  be 
prohibited.  In  most  cases  a  nerve  tonic  is  needed,  and  excellent  results 
may  be  obtained  from  the  administration-of  one  to  three  drops  of  tinc- 
ture of  nux  vomica  or  Fowler's  solution,  to  which  a  nerve  sedative, 
such  as  Dover's  powder,  1  to  3  grains,  or  a  combination  of  tincture 
of  belladonna  and  sodium  bromide  should  be  added  to  relieve  the 
excessive  nervous  irritability.  Bismuth  subnitrate  in  from  2-  to  10- 
grain  doses,  according  to  the  age  of  the  child,  should  be  given  .every 
three  hours  for  one  or  two  days  if  the  bowels  are  loose. 

DIARRHEA. 

Diarrhea,  one  of  the  most  common  affections  of  infancy  and  child- 
hood, is  said  to  exist  when  the  stools  become  loose  and  watery,  and  are 
much  increased  in  number.  It  is  alw^ays  a  sign  of  some  intestinal  dis- 
order, since  it  is  caused  by  increased  peristalsis  and  increased  intes- 
tinal secretion.  Moreover,  sinxje  diarrhea  results  in  marked  disturb- 
ance of  digestion  and  nutrition,  the  diseases  of  infancy  in  which  it  is 
the  most  prominent  symptom  have  by  far  the  highest  mortality. 

Etiology. — Diarrhea  is,  as  a  rule,  observed  in  children  from  six 
months  to  two  years  of  age,  a  fact  largely  accounted  for  by  the  liquid 
diet  which  they  receive  at  this  period  of  life.  It  does  not  occur  in  the 
breast-fed  infant  unless  there  is  some  disturbance  of  lactation,  hence 
its  comparative  infrequency  before  the  sixth  month.  But  the  fact  that 
90  per  cent,  of  cases  of  diarrhea  are  seen  in  bottle-fed  infants  seems 
almost  proof  positive  that  in  improper  feeding  lies  the  chief  cause. 
The  error  in  diet  may  be  either  overfeeding,  faulty  composition  of  the 
formula,  or  contamination  of  the  milk;  here,  again,  the  great  prevalence 
of  diarrhea  in  the  summer  time  would  seem  to  indicate  that  unsuitable 
or,  more  likely,  spoilt  milk,  plays  a  large  part  in  the  diarrheas  of  infancy. 

In  large  cities  the  number  of  cases  of  diarrhea  and  the  mortality  vary 
each  summer  in  direct  proportion  to  the  height  of  the  temperature 
and  duration  of  the  hot  spells,  which  shows  also  the  effect  of  excessive 
heat  in  the  production  of  this  disease.    Milk  may  also  be  unfit  for  use 


332  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

because  of  containiiuitiuii  by  filth  from  the  stable,  street,  or  store; 
hence  the  poorer  classes  furnish  most  of  the  cases  of  diarrhea  which 
are  due,  in  an  indirect  way,  to  unhygienic  surroundings,  poorly  kept 
food,  also  to  lack  of  fresh  air,  cleanliness,  and  sunshine.  Fatalities 
from  infantile  diarrhea  are  far  more  numerous  where  there  is  a  consti- 
tutional dyscrasia,  such  as  tuberculosis,  syphilis,  rachitis,  or  malfor- 
formation,  from  any  cause  whatsoever. 

Classification. — ^There  are  two  main  groups  of  diarrheas:  the  simple, 
or  non-infectious,  and  the  infectious.  Simple  diarrhea  may  be  clas- 
sified as  follows: 

Mechanical. — That  produced  by  indigestible  articles  of  food  which 
act  as  foreign  bodies  in  the  intestinal  tract.  In  these  cases  the  diarrhea 
is  an  indication  of  Nature's  desire  to  rid  the  intestines  of  the  irritating 
material,  hence  the  best  treatment  is  an  initial  purge  to  sweep  out  the 
offending  substance,  after  which  recovery  is  usually  prompt. 

Medicinal. — In  some  infants  the  laxative  effect  of  an  ordinary 
cathartic  will  persist  indefinitely.  The  milk  of  the  mother,  too,  has 
a  cathartic  effect  after  she  has  taken  certain  purgatives. 

Eliminatine . — Here  diarrhea  may  be  a  demonstration  of  Nature's 
effort  to  rid  the  system  of  toxins  by  way  of  the  bowel;  for  instance, 
eliminative  diarrhea  is  seen  in  uremia,  and  occasionally  in  acute  infec- 
tious diseases. 

Reflex. — Reflex  diarrhea  due  to  nervous  shock,  such  as  great  fright, 
or  excitement,  is  rather  rare  in  children,  but  does  occur,  and  is  char- 
acterized by  an  excess  of  mucus  in  the  stools.  Occasionally  diarrhea 
is  brought  on  by  chilling  the  surface  of  the  body. 

Treatment  of  Diarrheas. — The  first  step  in  the  treatment  of  a  simple 
diarrhea  is  to  ascertain  the  cause  and  remove  it.  In  the  majority  of 
instances  it  is  good  therapy  to  give  a  full  dose  of  castor  oil,  after  which 
bismuth  may  be  administered  in  fairly  large  doses,  5  to  10  grains,  every 
two  or  three  hours  for  a  day  or  two.  In  the  severe  diarrhea  of  infancy 
it  is  well  to  stop  all  milk,  and  give  nothing  but  water  for  24  to  48  hours. 
In  less  severe  cases  barley-water,  rice-water,  egg  albumen,  or  very  weak 
broth  may  be  substituted  for  the  milk  in  order  that  the  child  should 
not  suffer  from  utter  lack  of  nourishment,  and  as  soon  as  improvement 
sets  in  milk  feeding  should  be  resumed,  beginning  with  very  small 
quantities. 

INTESTINAL   BACTERIA. 

At  birth  the  intestines  contain  no  bacteria,  but  shortly  after  nursing 
is  begun  the  B.  lactis  aerogenes,  B.  coli  communis,  and  putrefactive 
organisms  may  be  found  in  the  intestinal  contents.  The  stool  of  a 
normal  infant  may  reveal  just  as  many  organisms  as  that  of  the  child 
who  is  ill ;  but,  for  the  most  part,  they  are  non-pathogenic,  and  practi- 
cally include  all  the  bacteria  found  in  the  mouth.  It  is  quite  generally 
believed  that  the  presence  of  certain  bacteria  in  the  intestinal  tract  is 
essential  to  good  health,  since  if  they  are  continually  destroyed  in  the 
milk,  the  infant  is  liable  to  develop  scurvy.    The  Bacillus  acidophilus 


MUCOUS  COLITIS  333 

is  invariably  to  be  found  in  the  mouth  and  intestines,  and  the  B. 
bifidus  communis  is  often  detected  in  the  stools  of  breast-fed  infants. 
Lactic  acid  is  formed  in  the  intestines  by  the  action  of  the  Bacillus 
lactis  aerogenes,  which  depends  for  its  growth  upon  milk  sugar,  and 
therefore  invades  the  upper  intestine,  also  by  the  action  of  the  Bacillus 
coli,  which  lives  upon  intestinal  secretions.  In  addition  to  these  organ- 
isms, saprophytes,  non-pathogenic  cocci,  the  B.  subtilis  and,  occasion- 
ally, the  bacillus  of  Shiga,  are  found  in  the  stools  of  normal  infants, 
although  the  Shiga  bacillus  is  the  organism  responsible  for  acute 
gastro-enteric  infection  in  infancy. 

MUCOUS   COLITIS. 

Mucous  colitis,  or  mucous  disease,  is  a  chronic  inflammation  of  the 
intestines  characterized  by  intestinal  indigestion  and  an  excessive 
production  of  mucus,  with  the  formation  on  the  mucosa  of  a  pseudo- 
membrane  which  is  passed  at  intervals  in  the  form  of  casts  of  the 
intestine  and  in  ropy  masses.  The  disease  is  essentially  the  same  as 
that  which  occurs  in  the  adult  and,  as  a  rule,  the  signs  and  symp- 
toms are  similar. 

Etiology. — This  disease  is  most  common  in  delicate,  neurotic  children 
who  are  of  neuropathic  ancestry  and  precocious.  It  is  very  rare  during 
infancy,  usually  occurring  between  the  ages  of  five  and  twelve  years. 
There  may  be  a  history  of  antecedent  catarrhal  colitis  or  of  frequent 
attacks  of  intestinal  indigestion. 

Symptoms. — Mucous  colitis  is  apt  to  appear  in  recurrent  attacks 
during  which  the  child  is  acutely  ill,  complains  of  severe  abdominal 
pain,  and  passes  casts  of  the  intestine  and  shreds  of  mucus  in  the  stools. 
As  a  rule,  there  is  constipation,  with  hard  dry  movements  which  are 
covered  with  mucus.  Occasionally  a  stool  is  normal  except  that  it 
contains  large  quantitites  of  mucus.  The  appetite  is  capricious,  the 
tongue  coated,  the  skin  pale  and  anemic-looking.  The  child  is  irritable 
and  peevish  during  the  day  and  very  restless  at  night;  often  it  is  under- 
nourished and  loses  weight.  The  attacks  are  brought  on  by  indiscre- 
tions in  diet  or  by  nervous  excitement  such  as  that  which  fright  and 
competitive  games  produce. 

Diagnosis. — The  diagnosis  is,  as  a  rule,  readily  made  upon  finding 
mucous  casts  of  the  intestines  and  an  excessive  number  of  mucous 
shreds  in  the  stools.  The  character  of  the  stools  will  enable  us  to 
differentiate  attacks  of  mucous  colitis  from  the  abdominal  pain  due  to 
appendicitis;  while  a  careful  study  of  the  signs  and  symptoms  and 
consideration  of  the  history  will  differentiate  it  from  tuberculous 
peritonitis,  which  it  occasionally  resembles. 

Prognosis. — The  outlook  is  favorable  for  final  recovery;  but  the  dis- 
ease runs  a  protracted  course  with  frequent  exacerbations  and  relapses. 

Treatment. — If  necessary  the  bowels  should  be  regulated  by  an  even- 
ing dose  of  fluidextract  of  cascara  sagrada,  20  to  30  drops.  Enemata 
and  colonic  irrigations  are  contraindicated  because  of  their  tendenc\- 


334  DISEASES  OF   THE  GASTRO-I NTESTI NAL   TRACT 

still  further  to  irritate  the  colon,  but  a  glycerin  suppository  may  be 
used  occasionally. 

Dietetic  treatment  is  of  the  utmost  importance,  the  progress  of  the 
case  depending  upon  the  careful  and  continued  regulation  of  the  diet, 
since  each  indiscretion  is  followed  by  a  relapse.  Carbohydrates  are 
esj^ecially  harmful  in  these  cases,  and  all  sugars  and  starches  should 
be  limited.  Pastries,  cakes,  candies,  potatoes,  and  bread  must  be  pro- 
hibited or  greatly  restricted,  and  broths,  stewed  fruits,  cereals,  and 
meats  substituted.  Toast  may  be  given  in  place  of  fresh  bread.  As 
a  rule,  milk  is  harmful. 

These  children  are  anemic  and  below  par,  and  they  require  tonic 
doses  of  tincture  of  nux  vomica,  one  to  three  drops,  or  Fowler's  solution, 
one  to  tliree  drops,  after  meals.  Improvement  is  much  more  rapid  if 
a  change  of  climate  can  be  secured  by  sending  the  child  to  the  sea- 
shore or  mountains. 


AMYLOID    DISEASE    OF    THE   INTESTINES. 

Amyloid  disease  of  the  intestines  is  rare  dm-ing  infancy,  but  may  be 
seen  occasionally  in  association  with  amyloid  disease  of  the  liver, 
spleen,  or  kidney.  The  exact  metabolic  changes  which  cause  the  depo- 
sition of  lardaceous  material  is  not  understood,  but  the  disease  attacks 
children  who  are  afflicted  with  syphilis,  tuberculosis,  or  some  chronic 
suppurative  process. 

Pathology. — ^At  the  onset  of  the  disease,  a  lardaceous  substance  is 
deposited  in  the  walls  of  the  small  vessels  of  the  intestinal  villi,  and  is 
later  found  also  in  the  mucosa  and  submucosa. 

Symptoms. — This  disease  gives  rise  to  no  definite  or  characteristic 
symptoms,  and  the  diagnosis  is  made  only  at  autopsy. 

Treatment. — There  is  no  specific  treatment  for  amyloid  disease; 
but,  in  cases  where  it  is  suspected,  the  underlying  cause  should  be 
ascertained,  and  removed  if  possible. 

INTESTINAL    OBSTRUCTION. 

Obstruction  of  the  intestines  may  be  either  congenital  or  acquired 
and,  while  the  congenital  form  is  the  one  usually  met  with  during 
childhood,  the  acquired  type  is  by  no  means  uncommon.  The  affec- 
tion when  acquired  is  the  result  of  intussusception,  strangulated  hernia, 
volvulus,  impaction  of  a  foreign  body  in  the  intestine,  peritonitis, 
constricting  bands,  or  the  pressure  of  intra-abdominal  tumors.  The 
congenital  form  is  due  to  malformation  of  the  intestinal  tract,  hernia 
of  the  umbilical  cord,  imperforate  anus  or  rectum,  or  other  anatomical 
anomaly. 

Symptoms. — The  symptoms  of  complete  obstruction  of  the  bowels 
are  vomiting  and  the  passage  of  a  small  amount  of  feces  mixed  with 
blood  and  mucus,  after  which  there  is  absolutely  no  movement  of 
the  bowels.     Vomiting  persists,   and  becomes   stercoraceous   if  the 


APPENDICITIS  335 

obstruction  is  not  relieved,  while  pain  is  severe  and  paroxysmal. 
The  pulse  soon  becomes  weak,  exhaustion  and  prostration  ensue, 
and  sepsis  quickly  supervenes  from  the  absorption  of  toxins.  The 
temperature  is  high;  the  abdomen  is  distended  and  tympanitic. 
If  the  obstruction  is  not  relieved  the  gut  now  becomes  gangrenous, 
pain  ceases,  sepsis  is  profound,  and  the  child  dies  in  collapse  within 
twenty-four  hours  from  the  time  gangrene  sets  in. 

Diagnosis. — The  diagnosis  is  based  upon  the  history  of  absolute 
constipation,  persistent  vomiting  which  becomes  stercoraceous,  and 
symptoms  of  collapse  with  severe  abdominal  pain,  together  with  other 
symptoms  which  vary  according  to  the  nature  of  the  obstruction. 

Prognosis. — The  prognosis  of  intestinal  obstruction  is  at  the  best 
unfavorable.  The  chances  of  recovery  are  greatest  in  those  cases 
in  which  the  diagnosis  is  made  early.  After  gangrene  has  set  in  death 
is  almost  a  certainty. 

Treatment. — The  treatment  is  wholly  surgical,  and  consists  in 
abdominal  section  and  removal  of  the  obstruction.  If  a  portion  of 
the  gut  is  gangrenous,  resection  is  also  necessary. 

VOLVULUS. 

Volvulus  is  a  twisting  of  the  bowel  upon  itself  in  such  a  way  that 
its  lumen  is  occluded  and  obstruction  is  the  result.  The  onset  is 
sudden,  and  is  marked  by  severe  pain  followed  by  absolute  stoppage 
of  the  bowels.  The  abdomen  is  distended  and  extremely  tender, 
but  there  is  rarely  stercoraceous  vomiting.  It  is  impossible  to  find 
a  tumor  either  by  abdominal  palpation  or  rectal  examination.  The 
symptoms  rapidly  become  aggravated,  but  collapse  does  not  appear 
as  quickly  as  in  other  forms  of  bowel  obstruction.  This  condition  is 
very  rare  in  children;  when  it  occurs  the  sigmoid  is  most  frequently 
the  portion  of  bowel  involved,  and  the  treatment  is  surgical. 

APPENDICITIS. 

This  affection  is  of  much  less  frequent  occurrence  in  children  than 
in  adults,  and  is  extremely  rare  during  infancy.  The  majority  of 
cases  are  observed  in  children  between  five  and  fifteen  years  of  age. 
The  acute  form  is  the  more  common  and,  as  a  rule,  an  attack  of 
appendicitis  runs  a  much  more  rapid  course  in  children  than  in  adults. 
Chronic  appendicitis  is  very  infrequent  during  childhood.  In  many 
respects  the  disease  presents  quite  a  different  aspect  in  the  child,  the 
symptoms  being  more  obscure,  and  the  appendix  lying  farther  above 
the  pelvic  brim  than  in  the  adult,  which  makes  the  seat  of  tenderness 
and  pain  above  McBurney's  point.  The  treatment  also  dift'ers  to  a 
certain  extent  from  that  in  the  adult. 

Etiology. — Appendicitis  is  more  common  in  boys  than  in  girls,  and 
becomes  more  frequent  as  the  child  advances  from  infancy.  Its  rarity 
in  children  before  the  second  year  is  due  to  the  infant's  liquid  diet 


336  DISEASES  OF   THE  GASTRO-INTESTINAL    TRACT 

and  the  relatively  wider  lumen  of  the  appendix  at  this  age.  Heredity 
may  be  considered  a  predisposing  cause  when  a  tendency  to  constipa- 
tion is  inherited  or  when  certain  anomalies  of  the  appendix  are  observed 
in  successive  generations  of  a  family.  Fecal  concretions  which 
block  the  lumen  of  the  appendix  are  the  cause  of  most  of  the  acute 
attacks,  but  obstruction  of  the  appendix  is  rarely  due  to  a  foreign 
body.  . 

In  many  instances  there  is  a  history  of  digestive  disturbance  and 
constipation;  but  these  conditions  may  be  regarded  merely  as  pre- 
disposing factors,  since  bacteria  are  the  exciting  cause  in  every  case. 
An  extension  of  intestinal  inflammation  into  the  appendix  may  pro- 
duce appendicitis;  but  this  is  infrequent,  and  only  in  exceptional 
cases  do  we  elicit  a  history  of  preceding  injury  to  the  abdomen  or 
of  intestinal  parasites.  The  aft'ection  is  occasionall}'  associated  with 
acute  infectious  diseases,  such  as  scarlet  fever,  follicular  tonsillitis, 
and  typhoid  fever. 

Pathology. — The  same  forms  of  acute  appendicitis  are  observed 
in  children  as  in  the  adult — the  catarrhal,  suppurative,  perforative, 
and  gangrenous.  Ulceration  or  perforation  is  quite  common,  and 
increases  the  gravity  of  appendicitis  in  children.  Catarrhal  appen- 
dicitis is  characterized  by  swelling  and  rigidity  of  the  appendix,  hyper- 
emia of  the  mucous  membrane,  and  infiltration  of  the  walls  with 
round  cells.  The  lumen  of  the  appendix  is  almost  obliterated,  and 
usually  contains  fecal  concretions  and  mucus  or  mucopus. 

In  inflammation  of  the  appendix  in  children  there  is  a  marked 
tendency  to  pus  formation  and,  as  a  consequence,  the  catarrhal  type 
is  usually  followed  by  suppuration.  In  a  few  instances  recovery 
ensues  without  pus  formation,  while  more  rarely  chronic  catarrhal 
inflammation  may  follow.  In  suppurative  appendicitis  the  inflam- 
mation of  the  appendix  is  more  severe  owing  to  the  deficient  blood 
supply  and  more  virulent  infection;  all  the  coats  of  the  organ  are 
involved,  and  its  lumen  is  filled  with  pus.  In  acute  appendicitis  in 
children  the  tendency  is  toward  abscess  formation;  but,  although 
perforation  is  not  infrequent,  peritonitis  is  rare,  for  the  abscess  is 
usually  walled  off  by  adherent  omentum. 

Gangrenous  appendicitis  is  the  result  of  an  obstruction  to  the 
circulation  in  the  appendix  which  causes  the  tip  to  become  necrotic. 
As  in  the  perforating  form,  the  contents  of  the  appendix  are  discharged 
through  the  opening  thus  made,  and  this  sets  up  a  localized  or  general 
peritonitis  according  to  whether  or  not  there  are  inflammatory  adhe- 
sions to  limit  the  spread  of  infection. 

Localized  gangrene  of  the  appendiceal  wall  from  pressure  of  a 
large  fecal  concretion  is  the  usual  cause  of  perforation  of  the  appendix; 
but  in  these  cases  peritonitis  does  not  assume  the  grave  septic  aspect 
commonly  observed  in  gangrenous  appendicitis.  Intestinal  obstruc- 
tion following  acute  appendicitis,  and  due  to  strangulation  of  the  gut 
and  inflammatory  adhesions  about  the  appendix,  while  comparatively 
rare,  occurs  t\  ith  greater  frequency  in  children  than  in  adults.    Chronic 


APPENDICITIS  337 

appendicitis,  although  seldom  seen  in  children,  may  be  the  sequel  to 
several  acute  catarrhal  inflammations.  At  autopsy  the  appendix 
is  found  to  be  thickened,  tortuous,  and  bound  down  by  adhesions  to 
the  adjacent  tissues. 

Bacteriology. — WTiile  inflammation  of  the  appendix  can  be  attributed 
to  no  special  organism,  yet  in  the  majority  of  cases  in  which  bac- 
teriological studies  have  been  made  the  colon  bacillus  has  been  found 
in  large  numbers.  Among  the  other  organisms  isolated  are  typhoid 
and  tubercle  bacilli,  and  the  streptococcus  and  staphylococcus. 

Associated  Lesions. — Appendicitis,  especially  the  acute  suppurative 
form  with  abscess  formation,  is  occasionally  the  cause  of  suppuration 
in  other  organs.  This  tendency  to  secondary  abscess  is  more  marked 
in  children  than  in  adults.  Not  infrequently  an  abscess  may  be  dis- 
covered in  the  liver,  brain,  parotid  gland,  lung,  or  in  tissues  adjacent 
to  the  appendix. 

Symptoms. — ^Mild  catarrhal  appendicitis  often  escapes  recognition 
in  children,  owing  to  the  fact  that  the  symptoms  are  not  unlike  those 
of  acute  gastric  or  intestinal  indigestion.  There  are  pain  and  tender- 
ness in  the  abdomen,  but  these  are  rarely  referable  to  the  right  iliac 
fossa;  and,  unless  appendicitis  be  suspected  and  an  attempt  made 
to  elicit  tenderness  over  the  appendiceal  region,  no  local  symptoms 
may  be  apparent. 

The  onset  of  such  an  attack  is  sudden;  it  may  or  may  not  be  preceded 
by  gastro-intestinal  disturbance  as  manifested  by  anorexia,  general 
malaise,  and  either  constipation  or  diarrhea.  Vomiting  is  rather  a 
constant  feature,  often  persisting  until  the  attack  subsides.  There 
is  usually  a  hypersensitive  state  of  the,  bladder  with  frequent  and, 
sometimes,  painful  micturition,  and  by  rectal  examination  of  the 
cecal  region  we  can  often  detect  inflammation  of  these  parts. 

Rigidity  of  the  abdomen  is  not  so  valuable  a  diagnostic  sign  in 
children  as  in  adults,  since,  even  though  there  be  neither  pain  nor 
tenderness,  the  child  may  resist  all  efforts  to  palpate  the  abdomen. 
If  the  inflammation  is  but  slight,  the  temperature  does  not  ascend 
above  101°  or  102°  F.,  and  in  the  course  of  three  or  four  days  sub- 
sides. There  is,  however,  greater  elevation  of  temperature  in  children 
than  in  adults,  the  height  always  depending  upon  the  severity  of  the 
attack  except  when  gangrene  or  perforation  has  caused  the  tempera- 
ture to  fall. 

In  a  severe  attack  of  acute  catarrhal  ay'pendicitis  the  s\'mptoms  are 
much  more  pronounced  and  the  disease  more  clearly  defined.  The 
fever  may  rise  above  105°  F.;  the  pulse  is  rapid;  vomiting  and  pain 
are  severe.  There  is  distinct  tenderness  over  the  appendiceal  region, 
which  in  children  is  a  little  above  McBurney's  point,  and  the  right 
rectus  muscle  is  rigid.  If  the  abdomen  be  examined  before  rigidity 
appears,  it  may  be  possible  to  palpate  the  firm,  swollen  appendix  by 
making  pressure  on  the  back  opposite  to  McBurney's  point  with  the 
left  hand  while  palpating  deeply  in  the  region  of  the  appendix  and  down 
into  the  pelvis  with  the  fingers  of  the  right  hand. 
22 


338  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

In  ulcerative  or  perjoratiie  ap-pendicitis  the  symptoms  at  the  onset 
are  those  of  a  severe  form  of  acute  catarrhal  inflammation.  The 
attack  comes  on  suddenly  with  vomiting,  constipation,  fever  of  102° 
to  105°  F.,  and  severe  abdominal  pain.  At  first  the  increase  in  the 
pulse  rate  corresponds  with  the  elevation  of  temperature;  but  after 
perforation  the  temperature  usually  falls,  while  the  pulse  becomes 
more  rapid  and  thready. 

If  the  appendix  is  well  walled  off  by  the  omentum  and  inflammatory 
adhesions,  perforation  causes  merely  a  localized  peritonitis  which  is 
indicated  by  an  area  of  induration  about  McBurney's  point.  When 
suppuration  takes  place  an  abscess  forms,  and  the  patient  suffers  from 
chills  and  sweats.  At  this  stage  the  child  usually  assumes  a  charac- 
teristic posture;  it  lies  on  its  back  with  the  knees  drawn  up,  and  the 
abdomen  held  quite  rigid.  The  pulse  is  rapid,  the  tongue  coated; 
vomiting  continues;  the  face  wears  an  anxious,  pinched  expression. 

If  an  abscess  forms,  a  tumor-like  mass  may  be  felt  in  the  right  iliac 
fossa  and  the  whole  abdomen  be  distended;  but  fluctuation  is  difficult 
to  make  out  because  of  the  depth  of  the  suppurative  process.  Its 
location  depends,  however,  upon  the  situation  of  the  appendix.  If 
the  organ  lies  in  the  pelvis,  the  abscess  is  often  readily  perceptible 
upon  rectal  examination. 

Few  cases  are  allowed  to  proceed  beyond  this  stage  without  opera- 
tion; but  until  the  abscess  is  opened  it  continues  to  increase  in  size, 
pain  and  tenderness  persist,  the  child  stoops  or  limps  if  placed  upon 
its  feet,  and  the  temperature  remains  elevated.  As  a  rule,  fluctuation 
is  easily  detected.  The  abscess  either  ruptures  externally  through 
the  skin  or  empties  its  contents  into  the  general  peritoneal  cavity, 
and  thus  gives  rise  to  peritonitis.  In  rare  instances  the  pus  is  evacu- 
ated into  the  rectum,  bladder,  or  vagina,  and  peritonitis  does  not 
occur. 

Gangrenous  appendicitis,  while  most  severe,  is  not  accompanied  by 
any  characteristic  symptoms,  and  the  course  of  an  attack  is  so  decep- 
tive that  the  mortality  is  very  high.  This  is  because  the  child's 
exact  condition  is  not  recognized,  and  the  decrease  in  pain  and  tender- 
ness, and  decline  of  the  fever  which  accompanies  gangrene  of  the 
appendix,  are  mistaken  for  signs  of  recovery,  whereupon  operation  is 
postponed,  and  septic  peritonitis  develops  a  day  or  two  later. 

The  shock  from  rupture  of  a  gangrenous  appendix  is  profound,  and 
is  usually  attended  by  vomiting,  acute  pain,  and  collapse,  while 
ordinary  perforation  or  ulceration  of  the  appendix  causes  sharp  pain, 
a  fall  in  temperature,  and  accelerated  pulse  rate. 

General  peritonitis — which  follows  perforation  or  gangrene  of  the 
appendix  when  the  appendiceal  region  is  not  walled  off — is  marked 
by  a  rise  of  temperature,  weak,  thready  pulse,  rapid  and  shallow 
respirations,  cold  and  clammy  skin,  and  often  persistent  hiccoughs. 
The  face  wears  an  anxious  expression;  nausea  and  vomitmg  continue. 
The  child  is  constipated.  The  abdomen  is  distended  and  tympanitic, 
and  there  is  a  board-like  rigidity  of  all  the  muscles  of  the  abdominal 


APPENDICITIS  339 

wall.  General  peritonitis  is  most  common  in  gangrenous  appendicitis, 
the  disease  being  so  acute  that  there  is  usually  insufficient  time  for 
the  walling  off  of  the  appendix;  consequently,  when  it  ruptures  the 
contents  escape  into  the  peritoneal  cavity.  Recovery  from  general 
peritonitis  is  rare,  especially  from  the  form  which  follows  gangrene 
of  the  appendix,  this  being  usually  of  extremely  septic  type. 

Chronic  Appendicitis. — The  symptoms  of  chronic  appendicitis  are 
much  milder  than  those  of  the  acute  form.  There  is  a  history  of  one 
or  more  acute  attacks,  followed  by  more  or  less  complete  recovery; 
but  the  child  constantly  complains  of  pain  and  discomfort  in  the 
appendiceal  region.  There  may  be  slight  fever  at  intervals,  and  occa- 
sionally an  attack  of  appendiceal  colic  with  vomiting  and  constipation. 
These  children,  while,  perhaps,  not  as  healthy  as  the  normal  child, 
do  not  show  the  nervous  effects  of  chronic  appendicitis  which  are  so 
frequently  observed  in  adults  who  suffer  from  this  disease;  and,  as 
a  rule,  there  is  little  emaciation  or  debility. 

Diagnosis. — The  all-important  aid  to  the  diagnosis  of  appendicitis 
in  children  is  rigidity  of  the  abdominal  wall,  especially  on  the  right 
side,  together  with  accompanying  localized  symptoms,  such  as  pain 
and  tenderness  in  the  right  iliac  fossa.  In  the  absence  of  these  indi- 
cations of .  appendiceal  inflammation  the  diagnosis  is  very  difficult, 
and  may  be  impossible,  since  all  of  the  additional  signs  and  symptoms 
are  those  which  may  also  be  found  in  other  gastro-intestinal  affections. 
If  the  appendix  lies  in  an  anomalous  position,  appendicitis  is  rarel}' 
thought  of,  and  may  altogether  escape  recognition  unless  an  explora- 
tory operation  be  performed. 

It  is  highly  important  that  appendicitis  be  recognized  early;  at 
the  same  time,  because  of  its  similarity  to  many  other  diseases  of 
the  gastro-intestinal  tract,  careful  differentiation  is  often  necessary. 
Intestinal  colic  may  be  ruled  out  by  the  absence  of  fever  and  localized 
tenderness,  also  by  the  tendency  of  the  symptoms  to  subside  within 
a  short  time.  In  bowel  obstruction  there  is  neither  tenderness  nor 
pain  in  the  right  iliac  fossa.  In  intussusception  the  tumor  can  usually 
be  palpated  in  the  centre  of  the  abdomen  or  on  the  left  side,  and  may 
often  be  detected  by  rectal  examination.  The  stools  contain  blood 
and  mucus;  there  is  no  fever  at  the  onset;  constipation  becomes 
absolute.  Intussusception  is  also  rare  after  infancy,  while  volvulus 
is  so  extremely  rare  in  children  that  it  needs  no  consideration. 

For  a  day  or  so  it  may  be  impossible  to  exclude  acute  indigestion, 
enterocolitis,  and  colic  with  fever;  but,  after  the  lapse  of  twenty- 
four  hours,  colic  and  acute  indigestion  usually  show  marked  improve- 
ment with  cessation  of  the  pain  or  localized  tenderness  in  the  right 
iliac  fossa,  while  in  enterocolitis  the  constant  diarrhea  with  mucous 
stools  discloses  the  nature  of  the  affection. 

Right-sided  pneumonia,  especially  when  accompanied  by  diaphrag- 
matic pleurisy,  may  produce  signs  closely  simulating  acute  appen- 
dicitis. The  right  rectus  muscle  may  be  rigid,  and,  until  physical 
signs  appear  in  the  lungs,  a  diagnosis  is  frequently  impossible.    Rapid 


340  DISEASES  OF   THE  GASTRO-INTESTINAL  TRACT 

respiratory  rate,  limited  motion  of  the  right  chest,  and  negative  rectal 
examination  of  the  cecal  region  may  all  favor  pneumonia.  The  leuko- 
cyte count,  while  not  of  great  service  in  differentiating  appendicitis 
from  pneumonia,  is  a  valuable  adjunct  in  the  exclusion  of  gastro- 
intestinal disturbances,  such  as  acute  indigestion,  colic,  ileocolitis, 
and  intussusception. 

To  a  certain  extent  one  can  also  differentiate  acute  catarrhal  inflam- 
mation from  suppurative  appendicitis;  but  it  is  by  no  means  always 
possible.  As  a  rule,  a  comit  of  12,000  or  less  usually  signifies  catarrhal 
inflammation,  while  a  leukocytosis  of  20,000  or  over  indicates  suppura- 
tion. It  must  also  be  borne  in  mind  that  in  severe  acute  cases  there 
may  be  no  leukocytosis.  In  order  to  obtain  the  most  accurate  data 
from  a  blood  examination  in  appendicitis,  a  series  of  counts  should 
be  made,  since  a  rising  leukocytosis  is  far  more  significant  than  a 
single  high  count. 

Prognosis. — When  an  early  diagnosis  is  made,  and  the  case  is  operated 
upon  immediately,  the  prognosis  is  favorable.  In  mild  cases  of  acute 
catarrhal  appendicitis  the  outlook  is,  as  a  rule,  also  favorable;  but 
suppuration  and  abscess  formation  are  more  common  than  in  adults. 
Cases  of  appendicitis  which  are  operated  upon  late,  and  those  occur- 
ring in  children  under  five  years  of  age,  are  alike  more  unfavorable  as 
to  outcome. 

Treatment. — Rest  m  bed  is  imperative.  Diu-mg  the  early  stages  of 
inflammation,  an  ice-bag  should  be  kept  over  the  appendiceal  region. 
Nothing  should  be  given  by  mouth  but  water  or  albumen-water.  If 
pain  be  severe,  and  an  operation  is  to  be  performed,  opiates  may  be 
given  in  small  doses — |  to  ^  grain  Dover's  powder.  But  in  those 
cases  which  the  physician  must  treat  expectantly,  either  because  the 
diagnosis  is  not  clearly  established  or  operation  is  refused,  opiates  are 
contra-indicated,  since  they  mask  important  symptoms. 

An  enema  may  be  given  to  open  the  bowels;  in  some  cases  it  is 
well  to  place  the  child  in  a  sitting  posture  with  the  knees  flexed,  as 
suggested  by  Fowler,  and  give  salt  solution  by  slow  proctoclysis. 
When  the  diagnosis  is  positive,  surgical  interference  should  be  urged, 
and  no  further  attempt  need  be  made  to  treat  the  case  medicinally. 
If  operation  is  refused,  the  child  should  stay  in  bed  on  a  liquid  diet, 
and  the  bowels  be  kept  moving  daily  by  the  use  of  enemata.    • 

These  cases  must  be  closely  watched.  If  the  fever  contmues  and 
no  improvement  is  noted,  operation  is  demanded.  Any  sign  of  per- 
foration or  gangrene,  as  shown  by  a  drop  in  the  temperature  with 
accelerated  pulse  rate  and  evidences  of  shock,  calls  for  immediate 
operation.  If,  on  the  other  hand,  there  is  improvement  under  medi- 
cinal treatment,  the  case  may  be  allowed  to  proceed  to  recovery. 
An  interval  operation  should,  however,  be  advised,  since  one  attack 
of  appendicitis  is  usually  succeeded  by  others  until  the  appendix  is 
removed. 

The  treatment  of  chronic  appendicitis  is  surgical.  An  appendectomy 
should  be  performed  in  the  interim  between  acute  exacerbations.    In 


INTESTINAL  WORMS  341 

treating  appendicitis  in  children  the  medical  man  should  always 
secure  the  assistance  of  a  surgeon.  Owing  to  the  tendency  to  abscess 
formation,  operation  is  the  wisest  procedure  in  every  case. 

INTESTINAL   WORMS. 

Children  are  nowadays  much  less  frequently  infested  with  worms 
than  they  were  a  generation  or  so  ago,  and  it  is  today  the  consensus 
of  opinion  that  the  injurious  effects  of  intestinal  parasites  have  been 
greatly  overestimated.  The  same  varieties  are  found  in  children  as 
in  adults;  but  in  the  majority  of  children  the  parasites  present  are 
the  threadworm  and  the  roundworm. 

Etiology. — Children  of  the  poorer  classes  are  the  usual  hosts  of  these 
parasites,  the  disease  being  seen  less  commonly  in  private  practice. 
Infants  seldom  harbor  worms,  for  the  reason  that  parasites  gain 
entrance  to  the  body  through  the  ova  which  are  swallowed  with  food 
and  water,  or  are  carried  to  the  mouth  by  means  of  the  fingers,  or  are 
on  articles  picked  up  off  the  floor  or  street  by  young  children. 

Symptoms. — The  general  symptoms  produced  by  intestinal  worms 
are  indefinite  and  vague.  Anemia,  loss  of  weight,  diminished  appetite, 
and  peevishness  may  be  the  only  signs  that  the  child  is  ailing;  but  in 
severe  cases  we  find  vomitmg,  colic,  restlessness  and  moaning  at 
night,  a  constant  desire  to  pick  at  the  nose,  gritting  of  the  teeth,  and 
more  or  less  nervousness,  sometimes  even  convulsions. 

When  the  body  is  infested  by  intestinal  parasites  there  is  always 
secondary  anemia;  but,  in  addition,  there  are  other  and  more 
characteristic  changes.  Eosinophilia  usually  accompanies  all  forms 
of  intestinal  infestation,  but  is  most  marked  when  trichinae  are  present. 
In  trichiniasis  also  there  is  usually  leukocytosis.  Severe  secondary 
anemia  as  a  result  of  intestinal  parasites  may  exhibit  a  blood  picture 
not  unlike  that  of  pernicious  anemia.  Aside  from  these  general  con- 
stitutional symptoms  caused  by  animal  parasites,  there  are  other 
signs  and  symptoms  which  vary  more  or  less  according  to  the  particular 
type  of  worm  present. 

Cestodes. — The  Taenia  mediocanellata,  or  beef  tapeworm,  and  the 
Taenia  solium,  or  pork  tapeworm,  are  the  most  common  varieties. 
The  Bothriocephalus  latus,  or  fish  tapeworm,  and  the  Taenia  cucume- 
rina,  the  Taenia  nana,  and  the  Taenia  echinococcus  are  quite  rare. 
Among  the  nematodes,  the  Oxyuris  vermicularis,  or  threadworm,  the 
whipworm,  and  the  Ascaris  lumbricoides,  or  roundworm,  are  the  most 
common  forms  found  in  children.  The  hookworm,  or  Ankylostoma 
duodenale,  or  Uncinaria  duodenalis,  while  quite  common  in  the  South, 
is -rarely  seen  in  the  northern  part  of  the  United  States.  Trichmae 
seldom  infest  children,  since  the  ova  are  ingested  by  eating  uncooked 
pork. 

Taeniae,  or  Tapeworms. — Tapeworms  are  matured  or  fully  de- 
veloped larvae  from  the  muscles  and  solid  viscera  of  animals.  The 
ova  are  taken  into  the  bodies  of  various  animals,  and  carried  to  the 


342  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

solid  tissues,  especially  to  the  inuseles,  where  they  lodge,  and  in  two 
or  three  months  they  produce  cysts  the  size  of  a  pea  within  which 
there  forms  a  teenia  head  or  scolex.  If  the  flesh  containing  these  cysts 
is  eaten  uncooked,  a  tapeworm  will  develop  from  the  scolex,  and  the 
segments  of  the  tapeworm  will  mature  several  months  after  the 
fixation  of  the  scolex  in  the  intestine.  When  mature,  the  segments 
develop  male  and  female  generative  organs. 

Taenia  Solium,  or  Pork  Tapeworm. — The  pork  tapeworm  is  less 
common  than  the  Teenia  mediocanellata,  or  beef  tapeworm.  It  develops 
in  the  small  intestine  after  the  ingestion  of  raw^  or  underdone  measly 
pork.  Usually  there  is  but  one  worm  in  the  intestine,  but  there  may 
be  more  than  one.  The  Tsenia  solium  ranges  from  six  to  thirteen  feet 
in  length.  Its  head  is  rounded,  of  pin-head  size,  and  is  succeeded  by 
a  thread-like  neck,  then  by  segments  w^hich  gradually  become  shorter 
and  broader.  There  are  four  suckers  and  a  projecting  circle  of  twenty- 
six  long  and  short  booklets  about  the  head  of  the  taenia. 

The  segments,  w^hen  mature,  become  detached  and  are  passed  out 
of  the  intestine  with  the  feces.  They  are  a  little  less  than  a  half-inch 
in  length  and  one-quarter  of  an  inch  in  breadth,  but  vary  so  much 
in  shape  that  at  about  three  feet  from  the  head  they  are  quadrilateral. 
The  female  matrix  occupies  the  middle  of  each  segment,  and  is  pro- 
vided with  eight  to  fourteen  tree-like  branches  on  each  side.  The 
male  generative  organs  are  small  vesicles  in  the  anterior  portion  of 
the  segment.  The  sexual  opening  is  on  one  side  near  the  middle. 
The  ovarian  or  uterine  apparatus  of  a  mature  segment  contains  many 
thick-shelled  eggs,  each  of  which  holds  wdthin  it  an  embryo  with  six 
booklets. 

Taenia  Mediocanellata,  or  Beef  Tapeworm. — The  beef  tapeworm  is 
the  most  common  variety  met  with  in  the  human  being.  It  varies 
from  12  to  30  feet  in  length.  In  comparison  with  the  Taenia  solium,  or 
pork  tapeworm,  its  segments  are  thicker  and  broader,  being  approxi- 
mately f  of  an  inch  long  and  half  as  broad.  The  head  of  the  worm  is 
larger  and  thicker,  and  contains  suckmg  disks,  but  no  booklets.  The 
ova  are  larger,  and  the  ovarian  branches  of  the  female  matrix  are  more 
numerous. 

Bothriocephalus  Latus,  or  Fish  Tapeworm. — This  variety  of  tape- 
worm is  found  most  commonly  in  foreign  countries.  It  is  longer  than 
any  other  intestinal  parasite,  measuring  20  to  30  feet.  The  head  is 
unarmed  and  club-shaped;  it  has  two  longitudinal  suckers.  The  seg- 
ments are  broader  than  those  of  the  other  varieties  of  tapeworm,  and 
the  ovarian  apparatus  is  rosette-shaped  and  situated  in  the  centre. 
The  ova  are  larger  than  those  of  the  beef  or  pork  tapeworm,  and  have 
a  lid  at  one  end.  They  develop  only  in  fresh  water,  and  here  they 
form  an  embryo  which  is  eaten  by  fish,  These  embryos  form  cysts  in 
the  viscera  and  muscles  of  the  fish,  and  if  the  fish  are  eaten  raw  or 
only  partially  cooked  scolices  develop  in  the  intestine. 

Dwarf  Tapeworm — Taenia  Nana. — This  tapeworm  is  the  smallest 
variety  found  in  man,  measuring  from  |  to  1  inch  in  length,  and  g-^ 


INTESTINAL  WORMS  343 

of  an  Inch  in  width.  The  head  has  four  suckers,  a  rostehum,  and 
hooklets.  The  segments  are  yellowish,  short,  and  broad.  Ttenia 
nana  is  more  common  in  children  than  is  generally  supposed. 

Symptoms. — The  subjective  symptoms  of  tapeworm  are  vague  and 
indefinite,  and  are  directly  due  to  the  irritation  produced  by  the 
worm  within  the  intestine.  There  is  always  a  certain  amount  of 
gastro-intestinal  disturbance,  which  is  often  very  slight,  but  in  some 
cases  may  cause  diarrhea,  colicky  pains  in  the  abdomen,  and  either  a 
capricious  appetite  or  anorexia.  The  breath  is  foul;  at  intervals  there 
may  be  nausea  and  vomiting.  None  of  these  symptoms,  however,  is 
at  all  characteristic  of  intestinal  worms  any  more  than  it  is  pathog- 
nomonic of  other  derangements  of  digestion. 

These  children  are  usually  irritable  and  peevish  during  the  day 
and  extremely  restless  at  night  from  nervous  excitation;  but  the 
symptoms  referable  to  the  nervous  system  are  not  as  severe  as  those 
caused  by  the  roundworm,  and  convulsions  are  rarely  seen.  In  many 
cases  the  child  may  be  apparently  in  good  health ;  but  there  is  usually 
a  gradual  loss  in  weight,  accompanied  by  anemia  which  may  reach 
an  extreme  degree,  but  is  usually  slight  and  of  secondary  nature. 
Eosinophilia  is  also  a  common  finding  on  blood  examination. 

Diagnosis. — The  diagnosis  of  tapeworm  can  be  made  only  when  the 
segments  appear  in  the  stools,  and  when  their  presence  in  the  intestine 
is  suspected  a  purge  should  be  given  to  bring  about  their  expulsion. 
Since  the  treatment  for  the  different  varieties  of  tapeworm  differs 
slightly,  the  segments  and  the  head  should  be  examined  microscopically 
in  order  to  identify  the  particular  type  of  worm  present.  If  no  seg- 
ments are  passed,  the  feces  should  be  examined  microscopically  for 
the  ova,  which  are  quite  numerous  and  easily  found  if  a  tapeworm 
inhabits  the  intestinal  tract. 

Prognosis. — It  is  seldom  a  difficult  matter  to  expel  a  tapeworm,  and 
since  its  presence  causes  no  severe  symptoms  the  outlook  is  in  most 
cases  very  good.  The  only  possible  danger  to  life  arises  when  the 
eggs  of  the  pork  tapeworm  find  their  way  into  the  stomach.  When 
this  occurs  the  embryos  are  formed  in  the  intestinal  canal  and  may 
pass  through  the  intestinal  wall,  and  become  lodged  in  the  muscles, 
the  viscera,  or  even  in  the  brain. 

Treatment. — Prophylaxis  is  important,  and  consists  for  the  most 
part  in  prohibiting  for  the  use  of  the  child  any  beef  or  pork  which  has 
not  been  inspected.  This  is  especially  imperative  in  those  cases  where 
rare  beef  or  beef  juice  is  being  given  to  children,  and  here  the  mother 
sho'jild  personally  inspect  the  meat  for  cysticerci  before  she  prepares 
it  for  the  child.  These  cysticerci  will  look  like  small  cysts  the  size  of 
a  pea  in  the  beef.  When  practicable,  the  safest  and  surest  precaution 
against  tapeworm  is  thoroughly  to  cook  all  meat  and  fish,  as  this  abso- 
lutely destroys  the  cysticerci. 

Fecal  discharges  from  children  who  harbor  tapeworms  should  be 
carefully  disinfected  with  5  per  cent,  carbolic  acid  solution  before 
being  disposed  of,  to  prevent  infection  from  being  transmitted  to  other 


344  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

children  or  to  animals  by  the  ova  which  they  contain.  Care  is  also 
necessary  to  keep  the  child  from  reinfecting  itself  by  its  soiled  hands 
or  by  the  receptacle  into  which  the  stools  are  passed. 

The  most  widely  used  drug  for  the  expulsion  of  the  tapeworm  is 
aspidium,  or  male  fern  (filix  mas),  which  should  be  given  in  doses  of 
5  to  30  drops,  according  to  the  age  of  the  child.  Both  this  and  other 
drugs  used  for  the  expulsion  of  the  tapeworm  cause  more  or  less  irri- 
tation of  the  gastro-intestmal  tract;  therefore,  it  is  advisable  to  use 
as  little  as  possible,  and  in  order  to  facilitate  the  action  of  the  vermifuge 
the  following  plan  of  treatment  is  usually  resorted  to : 

The  night  before  the  vermifuge  is  to  be  taken,  the  child  is  given  a 
very  light  supper,  and  then  a  full  dose  of  castor  oil,  |  to  1  ounce. 
Another  dose  of  castor  oil  is  administered  before  a  very  light  breakfast 
the  next  morning.  Then  the  aspidium  is  given,  preferably  in  divided 
doses  three  hours  apart  until  the  proper  amount  has  been  taken,  when 
another  dose  of  castor  oil  is  admmistered. 

The  stools  are  carefully  examined  for  the  head  and  segments  of  the 
worm.  If  the  segments  continue  to  come  away  or  the  symptoms 
persist,  it  may  be  necessary  to  repeat  this  treatment  over  and  over 
until  the  head  is  found  in  the  stool;  for,  unless  it  is  passed,  the  worm 
will  grow  again.  One  or,  at  the  most,  two  treatments  will  usually  bring 
away  the  head. 

While  the  child  is  being  treated  for  tapeworm  special  attention 
should  be  paid  to  its  diet,  which  should  be  as  light  as  possible  to  aug- 
ment the  action  of  the  vermifuge,  and  also  to  lessen  the  danger  of 
gastro-intestmal  disturbances  from  its  irritating  effect. 

Other  drugs  used  to  expel  tapeworms  are  pelletierin,  dose  1  to  2 
grains,  infusion  of  pepo  or  pumpkin  seeds,  dose  1  dram,  and  an  emul- 
sion of  turpentine  containing  10  drops  of  tiu-pentine  to  the  dram. 
The  latter  is  given  in  teaspoonful  doses  every  three  hours  for  a  day  or 
two,  being  preceded  and  followed  by  castor  oil,  or  the  turpentine  may 
be  given  in  1-dram  doses  combmed  with  an  ounce  of  castor  oil. 
An  infusion  of  kooso  or  brayera  may  be  made  by  adding  a  half-ounce 
of  powdered  leaves  to  a  pint  of  water  and  of  acacia  m  equal  parts. 
From  2  to  8  ounces  of  this  may  be  given,  accordmg  to  the  age  of  the 
child,  and  should  be  followed  by  castor  oil.  Thymol  in  5-  to  30-grain 
doses  has  also  been  found  efficacious. 

Nematodes. 

This  variety  of  worms  is  much  moie  common  in  children  than  the 
cestodes.  More  than  one  worm  is  usually  present  at  a  time,  but  they 
do  not  attain  the  size  of  the  cestodes.  Among  the  most  common 
nematodes  found  in  children  are  the  roimd  worm,  threadworm,  whip- 
worm, trichina,  and  hookworm. 

Oxyuris  Vermicularis — Threadworm. — This  is  a  very  small  worm, 
also  called  the  pin-  or  seatworm,  which  inhabits  the  colon,  and  espe- 
cially the  rectum.    It  forms  in  such  great  numbers  that  large  masses 


INTESTINAL   WORMS  345 

composed  of  the  worms  may  be  passed  by  the  bowel.  They  are  quite 
commonly  found  in  children,  but  may  also  infest  adults.  The  female 
worm  is  white  in  color,  and  about  half  an  inch  long,  while  the  male 
is  but  i  of  an  inch  in  length.  They  develop  from  ova  in  about  two 
weeks  after  the  ingestion  of  the  eggs,  which  are  of  an  irregular  ovoid 
shape,  and  5^0^  of  an  inch  in  length. 

By  the  time  the  embryos  reach  the  cecum  they  are  sexually  mature, 
and  when  the  female  arrives  in  the  rectum  she  deposits  there  immense 
numbers  of  eggs  that  mature  into  myriads  of  worms  which  are  dis- 
charged with  the  feces.  Infection  with  the  ova  may  take  place  by 
means  of  water  or  food,  and  also  through  the  uncleanliness  of  persons 
infested.  Scratching  about  the  anus  results  in  contamination  of  the 
hands  which  soil  anything  they  touch,  and  thus  spread  the  infection. 

Symptoms. — Itching  and  irritation  about  the  anus  and  genitalia 
are  the  most  characteristic  symptoms  of  threadworms.  The  irritation 
of  the  colon  may  also  cause  a  constant  discharge  of  mucus  from  the 
rectum.  The  child  suffers  most  from  the  itching  in  the  evening,  for 
at  this  time  the  worms  migrate  and  get  into  the  folds  of  the  rectum. 
During  the  day  the  child  is  very  restless,  and  constantly  scratches  the 
buttocks. 

Incontinence  of  urine  is  occasionally  due  to  threadworms,  and 
frequent  micturition  is  a  common  symptom.  As  with  roundworms, 
picking  at  the  nose  and  grinding  the  teeth  are  rather  characteristic, 
and  indicate  disturbance  of  the  nervous  system;  while  anemia,  loss 
of  appetite,  and  loss  of  weight  show  the  effects  of  threadworms  upon 
the  general  health  of  the  child. 

Sometimes  there  is  an  accompanying  catarrhal  colitis,  and  vulvo- 
vaginitis or  balanitis  may  also  be  attributed  to  threadworms  because 
the  itching  produced  so  easily  leads  to  the  habit  of  masturbation. 
Severe  consequences  from  threadworms  are  rare;  but  appendicitis 
has  been  traced  to  an  accumulation  of  these  parasites  in  the  intestine, 
and  convulsions  occasionally  supervene. 

Diagnosis. — Obstinate  pruritus  in  children  should  make  the  physician 
suspect  the  presence  of  threadworms  as  a  causative  factor,  and  the 
stools  should  be  examined  for  ova.  A  positive  diagnosis  is,  however, 
impossible  until  either  the  worms  or  their  ova  are  found  in  the  feces. 

Prognosis. — In  the  majority  of  cases,  all  of  the  worms  may  be  swept 
out  of  the  intestine  in  a  short  time  by  proper  treatment;  but,  occa- 
sionally, it  is  difficult  to  rid  the  child  of  the  parasites,  either  because 
they  are  in  the  cecum  where  injections  do  not  reach  them  or  because 
the  child  is  allowed  to  become  contaminated  and  continuously  rein- 
fected via  the  mouth. 

Treatment. — When  the  worms  are  all  in  the  lower  part  of  the  colon, 
enemata  will  often  suffice  for  their  removal.  The  lower  bowel  should 
first  be  irrigated  with  warm  salt  solution  to  wash  out  all  of  the  feces 
and  mucus,  and  then  an  infusion  of  quassia  or  garlic,  or  a  1  to  10,000 
solution  of  bichloride  of  mercury,  should  be  injected,  6  or  8  ounces 
being  allowed  to  remain  within  the  bowel  for  an  horn".     In  order  to 


346  DISEASES  OF  THE  GASTRO-INTESTINAL   TRACT 

clean  out  the  colon  eft'ectually  a  long  rectal  tube  should  be  used  for 
the  injection. 

But  the  threadworms  are  often  lodged  so  far  up  in  the  bowel  that 
this  treatment  is  unsuccessful,  therefore  santonin,  and  calomel,  of 
each  J  to  I  a  grain,  or  the  fluid  extract  of  quassia,  10  to  20  drops, 
should  be  given  prior  to  the  irrigation,  and  in  addition  a  purge  of 
castor  oil,  2  drams  to  an  ounce,  or  magnesium  sulphate,  1  dram  to 
half  an  ounce,  to  drive  the  parasites  into  the  lower  bowel.  It  is  advis- 
able to  repeat  the  saline  irrigation  and  the  injections  every  evening 
for  a  week,  by  which  time  most  children  will  have  been  cured. 

In  many  instances  examination  of  the  stools  will  fail  to  reveal  either 
ova  or  worms  after  the  second  or  third  injection;  but  when  they  have 
lodged  in  the  cecum  and  also  inliabit  the  small  intestine,  a  much 
longer  course  of  treatment  is  frequently  necessary. 

Treatment,  while  beneficial,  may  not  wholly  rid  the  child  of  thread- 
worms because  of  the  ease  with  which  reinfection  takes  place.  This 
is  usually  due  to  the  transmission  of  the  ova  from  the  contaminated 
clothing  and  buttocks  to  the  mouth  by  means  of  the  hands,  and  espe- 
cially the  finger  nails,  beneath  which  the  ova  lodge  when  the  child 
scratches.  For  this  reason  the  buttocks  should  be  carefully  cleansed 
and  bathed  with  a  1  to  10,000  bichloride  solution  after  each  bowel 
movement,  and  the  itching  should  be  controlled  by  anointing  the 
anus  with  a  dilute  mercurial  ointment  at  night  and  after  each  stool. 
All  underclothing,  diapers,  nightgowns,  and  bed  linen  should  be 
thoroughly  boiled  as  well  as  cleansed  when  soiled. 

The  stools  should  be  treated  with  5  per  cent,  carbolic  acid  solution 
before  being  disposed  of,  and  the  receptacle  they  are  passed  in  disin- 
fected. The  child,  if  old  enough,  must  be  taught  to  keep  the  hands 
clean  by  washing  them  whenever  they  have  come  in  contact  with  the 
buttocks,  and  the  finger  nails  should  be  scrubbed  with  soap  and  water 
to  dislodge  the  ova.  At  night  scratching  may  be  prevented  by  sewing 
up  the  sleeves  of  the  sleeping  garment. 

If  the  general  health  of  these  children  has  been  affected,  they 
should  be  put  upon  a  nourishing  but  light  diet,  encom-aged  to  play 
out  of  doors,  and  given  a  tonic  containing  tincture  of  gentian  or  quas- 
sia which  will  serve  the  double  purpose  of  building  up  the  system  and, 
to  a  certain  extent,  acting  as  a  vermifuge. 

Ascaris  Lumbricoides — Roundworm. — The  roundworm  occurs  more 
frequently  in  children  than  any  other  intestinal  parasite,  par- 
ticularly in  children  between  the  ages  of  three  and  ten  years.  It 
inhabits  the  upper  portion  of  the  small  intestine.  In  appearance  it 
is  very  much  like  the  common  earthworm,  its  body  being  round, 
fusiform,  and  of  a  reddish-brown  color.  The  female  is  7  to  14  inches 
long,  w^hile  the  male  measures  from  4  to  8  inches.  It  is  about  as  thick 
as  a  goose  quill,  and  the  head  is  furnished  with  three  oval  papillse 
which  have  fine  teeth. 

The  ova  are  elliptical  in  shape,  of  a  dark  reddish  color,  and  about 
0.05  mm.  long.    They  are,  in  all  likelihood,  ingested  with  water  and 


INTESTINAL  WORMS  347 

food.  At  times  these  worms  migrate  from  the  small  intestine,  having 
been  found  even  in  the  pharynx,  mouth,  nares,  larynx,  and  trachea, 
and  have  caused  asphyxia,  pulmonary  gangrene,  and  hepatic  abscess. 

Symptoms. — A  child  may  harbor  a  number  of  roundworms  in  the 
intestine  without  showing  any  sign  whatsoever  of  their  presence. 
Intestinal  irritation  may  give  rise  to  digestive  disturbances  with  colic, 
tympanites,  constipation  or  diarrhea,  and  loss  of  appetite,  or  even 
nausea  or  vomiting.  These  children  are  usually  very  restless  at  night 
and  peevish  during  the  day,  with  a  tendency  to  pick  at  the  nose 
continually  and  to  grind  the  teeth. 

Evidence  of  rectal  irritation  may  also  be  noticed,  but  is  not  charac- 
teristic, while  headache  is  not  uncommon.  Nervous  symptoms  are 
usually  mild;  but  occasionally  round  worms  may  cause  dizziness, 
hysteria,  syncope,  or  convulsions.  The  harmful  effects  of  roundworms 
on  the  nervous  system  are  supposed  to  be  due  to  the  absorption  of 
poisons  which  they  excrete  into  the  intestinal  canal.  Eosinophilia 
is  a  common  finding. 

Diagnosis. — It  is  scarcely  possible  to  make  a  diagnosis  of  round- 
worm infestation  upon  the  symptoms  enumerated  above;  therefore, 
unless  their  presence  is  suspected  and  the  stools  are  examined  for  ova, 
the  diagnosis  is  not  made  until  a  worm  is  passed  in  the  stool,  and 
discovered  by  the  child  or  its  parent.  The  stools  of  children  who  har- 
bor roundworms  always  contain  a  multitude  of  ova  which  are  easily 
detected  by  microscopic  examination.  As  a  rule,  several  worms  are 
present  in  the  intestinal  tract  at  one  time;  hence  the  persistence  of 
the  symptoms  after  the  passage  of  one  or  more  worms  indicates  that 
there  are  still  others  in  the  bowel. 

Treatment. — The  best  drug  for  expelling  roundworms  is  santonin. 
The  child  should  be  given  a  light  supper  and  a  half-ounce  to  one  ounce 
of  castor  oil  befoie  going  to  bed.  The  following  morning  santonin 
should  be  given,  combined  preferably  with  calomel.  A  child  one 
year  old  should  take  a  half-grain  three  times  during  the  day  with  the 
same  quantity  of  calomel.  This  dose  may  be  doubled  for  children 
over  three  years  old.  The  last  dose  of  santonin  is  given  in  the  evening, 
and  the  next  morning  from  1  to  .3  drams  of  magnesium  sulphate  should 
be  administered  before  breakfast. 

If  more  worms  are  passed  after  this  treatment  it  must  be  repeated 
until  they  are  no  longer  seen  in  the  stools  and  microscopic  examination 
of  the  feces  shows  the  absence  of  ova.  Other  vermifuges  which  may 
be  used  are  fluidextract  of  spigelia,  dose  |  to  1  dram,  and  senna.  To 
prevent  the  child  from  reinfecting  itself  the  hands  and  anus  must  be 
kept  perfectly  clean  and  as  free  from  ova  as  possible.  The  expulsion 
of  all  the  w^orms  is  usually  followed  by  a  cessation  of  the  symptoms, 
after  which  no  further  treatment  is  necessary  unless  the  child  has 
become  anemic,  when  an  iron  tonic  should  be  prescribed. 

Trichocephalus  Dispar. — The  Trichocephalus  dispar,  or  whipworm, 
frequently  accompanies  threadworms  when  they  infest  the  colon, 
but  its  presence  is  rarely  discovered.    This  parasite  closely  resembles 


348  DISEASES  OF   THE  G ASTRO-INTESTINAL   TRACT 

the  threadworm.  The  male  measures  3  to  4  cm.  m  length,  while  the 
female  is  somewhat  longer  and  sometimes  attains  a  length  of  5  cm., 
or  2  inches.  The  tail  end  of  the  female  is  conical  and  pointed,  while 
that  of  the  male  is  blunt  and  coiled  up  like  a  sprmg.  The  rest  of  the 
worm  up  to  the  head  is  slender  and  hair-like.  The  head  is  very  small, 
but  has  the  power  of  attaching  itself  most  firmly  to  the  intestinal  wall. 

The  ova  are  but  0.05  mm.  (0.0012  of  an  mch)  long,  and  have  a 
button-like  projection  at  one  end.  In  most  instances  this  parasite 
lodges  in  the  cecum,  although  it  may  also  inhabit  the  small  intestine 
and  the  appendix.  It  is  very  rarely  found  in  infants;  but  of  all  the 
parasites  that  infest  man  the  trichocephalus  is  said  to  be  more  common 
during  childhood  and  adult  life  than  any  other.  It  is  supposed  to 
gain  entrance  to  the  intestine  by  the  ingestion  of  the  ova  in  drinking 
water. 

Symptoms. — As  a  rule,  only  a  few  worms  are  in  the  intestine  at  one 
time,  therefore  the  symptoms  are  few  and  very  slight;  but  when  a 
large  number  of  these  parasites  collect  in  the  cecum  the  consequences 
may  be  serious.  In  such  cases  anemia  is  quite  marked,  and  even 
brain  symptoms  have  been  attributed  to  the  whipworm.  On  account 
of  the  usual  association  of  the  threadworm  with  the  whipworm,  the 
threadworm  being  present  in  far  greater  numbers,  it  seems  reasonable 
to  suppose  that  these  symptoms  are  only  in  part  due  to  the  Tricho- 
cephalus dispar. 

Diagnosis. — The  presence  of  this  parasite  is  rarely  diagnosed  during 
life,  although  the  ova  may  be  found  in  the  stools  and  identified  under 
the  microscope. 

Treatment. — In  order  to  prevent  the  whipworm  from  effecting 
entrance  to  the  intestine,  precautions  should  be  taken  to  ascertain 
the  purity  of  all  drinking  water.  Salt  solution  and  infusion  of  garlic 
or  quassia,  or  a  solution  of  1  to  10,000  bichloride  of  mercury,  should 
be  used  as  injections  in  the  manner  described  in  the  treatment  of 
threadworms;  but  it  is  usually  necessary  to  supplement  these  meas- 
ures by  the  oral  admmistration  of  drugs  because  of  the  habitat  of  the 
whipworm,  which  is  too  high  in  the  colon  to  be  effectively  reached 
by  rectal  irrigation  alone.  Calomel,  1  to  3  grains,  should  be  given, 
followed  by  a  full  dose  of  castor  oil. 

After  the  bowels  have  been  moved  a  vermifuge,  such  as  santonin, 
i  to  ^  of  a  grain,  repeated  in  six  hours,  fiuidextract  of  quassia,  10  to 
20  drops,  given  every  six  hours  for  three  doses,  or  tincture  of  podophyl- 
lin,  1  to  2  drops  every  six  hours  for  three  doses,  may  be  administered. 

Ankylostomum  Duodenale — Hookworm. — The  hookworm  is  a 
nematode  which  inhabits  the  duodenum  and  jejunum.  The  female 
is  about  a  half  inch,  and  the  male  one-third  of  an  inch  in  length.  The 
body  is  thread-like.  The  head  is  conical;  the  mouth  is  bell-shaped, 
is  surrounded  by  a  horny  capsule,  and  contains  four  hook-like  teeth. 
These  are  ventrally  situated,  and  on  the  dorsal  side  are  two  smaller 
vertical  teeth  by  which  the  worm  fastens  itself  to  the  mucous  mem- 
brane. 


INTESTINAL   WORMS  349 

The  eggs  are  deposited  in  muddy  water  or  in  warm,  moist  earth, 
and  there  the  embryos  are  hberated.  These  develop  into  larvse  which 
soon  pass  into  the  dormant  state  and  remain  quiescent  for  an  indefi- 
nite period  until  they  are  taken  into  the  stomach  by  means  of  drinking 
water,  food,  or  dirt — more  commonly  dirt  that  has  collected  on  the 
hands,  and  particularly  under  the  finger  nails. 

Direct  infection  through  the  skin  is  now  thought  to  be  the  usual 
mode  of  transmission,  the  parasite  entering  the  body  through  the 
skin  of  the  feet  and  legs  by  contact  with  contaminated  soil.  It  then 
is  carried  by  the  blood  stream  to  the  lungs,  passes  into  the  air  spaces, 
bronchi,  trachea,  esophagus,  or  stomach,  and  finally  reaches  the  small 
intestine.  Here  sexual  characteristics  develop  in  the  parasites,  repro- 
duction ensues,  and  the  ova  are  deposited  in  the  bowel,  but  they  do 
not  multiply  within  the  intestine.  Males  are  affected  with  hook- 
worm to  the  same  extent  as  females,  and  the  parasite  is  most  preva- 
lent in  children  between  the  ages  of  six  and  sixteen. 

Symptoms. — The  symptoms  of  hookworm  disease,  or  uncinariasis, 
are  to  be  attributed  chiefly  to  severe  toxemia  and  anemia.  There  is 
usually  abdominal  discomfort  or  pain,  progressive  emaciation,  and 
high-grade  anemia  resembling  the  pernicious  form.  Children  who 
are  infested  have  an  apathetic,  languid  expression,  and  look  much 
older  than  they  really  are.  They  are  stunted  mentally  and  physically, 
and  become  shiftless,  untruthful,  dishonest,  disobedient,  and  closely 
resemble  cretins.  The  face  is  puffy,  the  skin  muddy  and  sallow,  the 
abdomen  distended,  and  the  extremities  are  either  very  thin  or  swollen 
and  edematous. 

These  children  have  either  a  poor  or  ravenous  appetite  which  is 
usually  capricious,  and  they  not  infrequently  eat  earth  and  dirt, 
hence  their  name,  "dirt-eaters."  The  subjective  symptoms  include 
headache,  dizziness,  palpitation  of  the  heart,  dyspnea,  nausea,  and 
spells  of  vomiting.  The  bowels  are  usually  constipated,  and  the  stools 
contain  microscopic  and  occult  blood.  The  changes  in  the  viscera 
revealed  at  postmortem  are  cerebral  anemia  with  effusion  into  the 
ventricles  of  the  brain,  flabbiness  of  the  heart  muscle,  fatty  degenera- 
tion of  the  liver,  softening  of  the  spleen,  and  the  lesions  typical  of 
nephritis. 

Diagnosis. — A  definite  diagnosis  can  be  made  only  by  finding  the 
ova  and  the  hookworms  in  the  stools,  although  the  symptoms  in 
most  cases  of  uncinariasis  are  very  characteristic. 

Prognosis. — The  prognosis  is  good  if  the  case  is  diagnosed  early  and 
is  properly  treated;  but,  occasionally,  the  disease  runs  a  rapid  course 
and  the  patient  succumbs  from  exhaustion  within  a  few  weeks. 

Treatment. — Thymol  is  universally  recognized  as  a  specific  for  hook- 
worm disease.  The  maximum  amount  which  should  be  given  is  7f 
grains  to  children  up  to  the  age  of  five  years,  15  grains  to  children 
from  five  to  ten  years,  and  30  grains  to  those  between  ten  and  fifteen 
years.  Two  days  before  the  thymol  is  to  be  given  the  diet  should  be 
restricted  to  liquids,  and   a  dose  of  magnesium  sulphate  adminis- 


350  DISEASES  OF   THE  G ASTRO-INTESTINAL   TRACT 

tered,  this  being  repeated  on  the  following  day.  On  the  next  day 
the  thymol  is  given,  one-half  the  dose  at  6  a.m.,  and  the  remaining 
half  at  8  a.m.,  followed  two  hours  later  by  another  dose  of  magnesium 
sulphate.  The  child  should  then  be  made  to  lie  on  the  right  side  for 
two  hours. 

This  treatment  should  be  repeated  at  the  end  of  a  week,  and  ten 
days  later  the  stools  should  be  examined  for  ova  or  parasites.  If  none 
is  found,  no  more  thymol  need  be  given;  but  the  child  should  have 
plenty  of  fresh  air,  good  nourishing  food,  and  should  take  a  tonic 
such  as  Fowler's  solution,  1  to  3  drops  three  times  a  day,  or  the 
syrup  of  the  iodide  of  iron,  10  to  30  drops  three  times  a  day,  for  the 
anemia. 

Trichina. — The  Trichina  spiralis  is  a  vivaporous  worm  occasionally 
found  in  children.  The  male,  when  mature,  measures  yV  of  an  inch, 
and  the  female  -^2  to  ^  of  an  inch  in  length.  The  embryo  is  about  2V 
of  an  inch  long,  and  lies  coiled  up  in  a  spiral  within  an  ovoid  capsule 
in  the  sarcolemma  sheath  of  the  muscle  fiber.  The  mature  worm  has 
a  pointed,  unarmed  head.  The  neck  is  long  and  more  slender  than 
the  body,  which  has  a  round,  blunt  end. 

The  life  history  of  the  trichina  begins  when  the  larvse  become 
encysted  in  the  muscles.  When  this  flesh  is  eaten  by  another  animal 
or  by  man,  the  larvse  are  liberated  by  the  digestive  processes  and  pass 
into  the  intestines.  In  from  two  to  four  days  they  become  sexually 
mature,  and  five  to  seven  days  thereafter  they  produce  hundreds  of 
living  embryos.  The  intestinal  trichinae  reach  their  full  growth  and 
then  die  in  from  four  to  five  weeks. 

During  her  life  period  in  the  intestine  the  female  trichina  may  bring 
forth  several  broods  of  embryos.  The  living  embryos  migrate  from 
the  intestine  at  once,  and  invade  the  muscles  through  various  channels, 
principally  along  the  connective-tissue  routes,  so  that  the  symptoms 
of  muscular  irritation  develop  in  from  seven  to  ten  days  after  eating 
trichinous  meat. 

The  embryos  attain  maturity  about  two  weeks  after  they  invade 
the  muscle  tissue,  where  their  presence  sets  up  an  irritation  which 
in  from  four  to  six  weeks  causes  the  formation  of  a  fibrous  capsule 
about  the  trichina.  Usually  but  one  trichina  is  found  within  a  cap- 
sule, and  this  encapsulated  trichina  may  live  for  years  in  the  muscle, 
the  capsule  finally  becoming  calcified  so  that  it  may  be  easily  dis- 
cerned by  the  naked  eye. 

Symptoms. — After  meat  infested  with  trichinae  has  been  eaten  there 
is  usually  a  period  of  gastro-intestinal  disturbance,  followed  by  the 
symptoms  of  trichiniasis,  which  are  not  unlike  those  of  influenza, 
rheumatic  fever,  malaria,  or  typhoid  fever.  There  are  severe  pain  and 
soreness  in  the  muscles,  and  edema  of  the  face  and  eyelids  which 
suggests  nephritis.  These  symptoms  usually  persist  for  from  ten  days 
to  two  weeks,  during  which  time  the  disease  is  rarely  recognized. 

Diagnosis. — A  positive  diagnosis  can  be  made  only  by  removing  a 
section  of  muscle  tissue,  and  identifving  the  trichinse  within  it. 


ACUTE  PERITONITIS  351 

Treatment. — As  soon  as  the  diagnosis  is  made,  thorough  purging 
with  calomel,  1  to  3  grains,  should  be  instituted,  and  six  hours  later 
I  to  2  drams  of  magnesium  sulphate  should  be  administered.  Further 
treatment  is  merely  for  the  relief  of  symptoms,  since  it  is  doubtful 
whether  anything  can  be  done  to  arrest  the  progress  of  the  disease 
after  the  muscles  have  once  been  invaded. 

Morphin  sulphate,  5V  to  yV  o'^  a  grain,  may  be  given  hypodermically 
for  the  relief  of  pain  if  simpler  measures,  such  as  warm  baths  and 
hot  applications  to  the  muscles,  fail  to  give  relief.  Since  death  some- 
times occurs  from  exhaustion  or  the  severe  irritation,  the  child's 
strength  should  be  kept  up,  and  stimulation  resorted  to  whenever 
necessary. 

Among  the  drugs  said  to  be  effective  in  destroying  the  trichinae  are 
glycerin,  given  in  dram  doses  hourly,  benzine  in  5-  to  20^grain  doses, 
and  picric  acid  in  1-  to  2-grain  doses. 


DISEASES   OF   THE   PERITONEUM. 

ACUTE    PERITONITIS. 

i\.cute  peritonitis  is  extremely  rare  during  childhood,  and  non- 
tuberculous  chronic  peritonitis  is  practically  never  encountered. 
Acute  inflammation  of  the  peritoneum  is  always  a  secondary  process, 
although  in  some  cases  the  primary  factor  may  be  very  obscure.  It 
may  be  circumscribed  or  diffuse,  and  is  also  classified  as  serous  or  sup- 
purative, according  to  the  nature  of  the  exudate. 

Etiology. — Peritonitis  may  occur  in  the  fetus  from  syphilis  or  septic 
infection  of  the  mother;  but  it  is  seen  more  frequently  in  the  new- 
born than  at  any  other  period  of  childhood,  and  is  the  result  of  infec- 
tion of  the  umbilicus.  Appendicitis  is  the  most  common  cause  of 
acute  peritonitis  in  older  children,  but  it  is  also  occasionally  seen  in 
combination  with  inflammation  of  the  abdominal  viscera,  lungs,  pleura, 
or  pericardium.  Direct  violence  to  the  abdomen  is  responsible  for 
a  few  cases;  in  other  instances  it  may  be  traced  to  an  attack  of  typhoid 
fever,  pneumonia,  one  of  the  acute  infectious  diseases,  or  to  gonorrheal 
vulvovaginitis. 

Perforation  of  an  abdominal  viscus,  such  as  a  rupture  of  the  gall- 
bladder, abscess  of  the  liver,  ulcer  of  the  duodenum  or  stomach,  or 
a  typhoid  ulcer,  always  produces  peritonitis.  Sometimes  infection 
may  be  transmitted  from  an  empyema.  Intussusception  and  stran- 
gulated hernia,  if  not  reduced,  are  soon  followed  by  peritonitis,  and 
in  rare  cases  the  peritoneum  has  become  infected  through  a  ruptured 
cyst  of  the  liver,  spleen,  or  kidney.  Occasionally  the  infection  is 
carried  through  the  blood  stream,  and  in  this  manner  peritonitis  may 
complicate  suppurative  otitis  media  or  an  attack  of  meningitis. 
Infection  by  way  of  the  lymph  channels  has  also  been  proven. 


352  DISEASES  OF  THE  G ASTRO-INTESTINAL   TRACT 

Bacteriological  studies  have  shown  that  the  colon  bacillus,  pneumo- 
coccus,  Staphylococcus  aureus,  Streptococcus  pyocyaneus,  and  Strep- 
tococcus pyogenes  are  the  organisms  most  frequentlj^  present. 
Gonococci  may  occasionally  be  found  when  peritonitis  complicates 
gonorrheal  Mil vo vaginitis;  but  this  is  rare.  In  appendicitis  accom- 
panied by  peritonitis,  the  colon  bacillus  has  been  isolated  in  the 
great  majority  of  cases.  Pneumococcal  peritonitis,  which  has  a  special 
predilection  for  children,  may  complicate  pneumonia  or  pneumo- 
coccemia;  and  peritonitis  in  which  the  staphylococcus  or  streptococcus 
predominates  is  usually  due  to  an  acute  infectious  disease  or  ruptured 
abdominal  viscus. 

Pathology. — ^The  postmortem  findings  depend  altogether  upon 
the  character  of  the  inflammatory  process.  In  every  case  the  visceral 
and  parietal  peritoneum  is  found  to  be  intensely  congested  and 
hyperemic.  If  there  be  but  little  serous  exudate,  and  the  intestines 
are  covered  by  an  exudate  of  lymph,  or  are  bound  together  by  a 
fibrous  exudate,  fibrinous  peritonitis  is  recognized.  In  serous  peri- 
tonitis there  is  but  little  fibrin  in  the  exudate,  but  a  large  amount 
of  serum  is  found  in  the  peritoneal  cavity. 

Suppurative  peritonitis  is  characterized  by  the  formation  of  pus 
within  the  peritoneum.  This  is  usually  confined  to  that  portion  of 
the  peritoneal  cavity  surrounding  the  site  of  infection,  where  an  abscess 
forms;  but  in  severe  cases  it  may  be  present  throughout  the  whole 
abdominal  cavity.  ^Mien  a  collection  of  pus  is  found  walled  off  within 
the  peritoneal  cavity  by  the  formation  of  inflammatory  adhesions, 
the  condition  is  known  as  circumscribed  peritonitis,  in  contradistinc- 
tion to  the  diffuse  form  in  which  the  pus  is  free. 

Symptoms. — In  acute  peritonitis  the  symptoms  are  usually  very 
frank  and  acute;  but  occasionally  they  are  masked  by  the  primary 
and  associated  condition.  This  causes  great  difficulty  in  diagnosis, 
especially  in  infants  dm-ing  the  first  few  days  of  the  disease  when  the 
condition  is  not  suspected.  The  prominent  s^'Tnptoms  are  pain, 
tjTnpanites,  absolute  constipation,  persistent  vomiting,  and  high 
fever.  Pain  appears  first  at  the  point  of  infection,  e.  g.,  the  right 
iliac  fossa  or  umbilicus — but  soon  becomes  general  and  extends  over 
the  whole  abdomen. 

Vomiting  is  persistent,  occurring  usually  at  intervals,  and  increases 
in  severity  as  the  disease  progresses.  The  vomitus  is  composed  for 
the  most  part  of  a  greenish,  watery  liquid  which  contains  mucus. 
Hiccough  is  often  distressing,  and  may  be  regarded  as  an  unfavorable 
sign.  In  cases  where  there  has  been  an  antecedent  diarrhea,  this 
condition  may  persist;  and,  although  constipation  may  afterward 
take  its  place  as  a  result  of  paralysis  of  the  intestinal  muscles  which 
inhibits  peristalsis,  diarrhea  is  more  common  in  the  peritonitis  of 
childhood  than  in  adults. 

There  is  usually  an  initial  chill,  followed  by  a  sharp  rise  in  tem- 
perature to  103°  F.  or  even  higher.  The  pulse  is  weak  and  rapid; 
the  respirations  are  short  and  quick;  and,  while  the  body  may  be 


ACUTE  PERITONITIS  353 

hot  and  dry,  the  extremities  are  cold.  The  tongue  is  dry  and  brown; 
the  eyes  are  sunken;  the  child  lies  upon  its  back  with  its  knees  drawn 
up  to  relieve  the  tension  upon  the  abdominal  muscles.  The  urine  is 
high-colored,  concentrated,  and  scanty,  or  it  may  even  be  suppressed; 
upon  examination  it  is  found  to  contain  an  excessive  amount  of 
indican.  There  ♦is  always  leukocytosis  in  peritonitis;  but  unless  a 
blood  count  has  been  made  before  the  disease  is  suspected  this  is  of 
no  diagnostic  value,  since  it  may  be  due  to  the  primary  condition — 
appendicitis. 

Physical  examination  in  peritonitis  l-e veals  a  distended,  tender, 
tympanitic  abdomen  with  marked  rigidity  of  all  the  abdominal  muscles. 
In  circumscribed  peritonitis  the  pain  and  tenderness  are  confined 
to  the  site  of  the  abscess,  and  the  symptoms  are  not  as  severe  as 
in  the  diffuse  form.  Pneumococcal  peritonitis,  which  is  to  a  certain 
extent  localized,  is  characterized  by  an  encapsulated  collection  of  pus 
behind  the  anterior  abdominal  wall  just  below  the  umbilicus,  which 
forms  a  tumor  at  this  point. 

In  some  cases  of  this  variety  of  peritonitis,  the  skin  about  the  navel 
becomes  perforated  and  the  abscess  drains  externally,  whereupon 
recovery  ensues.  As  a  rule,  the  symptoms  of  peritonitis  due  to  gonor- 
rheal vulvovaginitis  are  very  mild,  and  the  infection  is  confined  to  the 
pelvic  peritoneum;  but  this  form  of  inflammation  of  the  peritoneum 
is  not  to  be  regarded  too  lightly,  since  the  infection  may  spread  through- 
out the  peritoneal  cavity  and  rapidly  prove  fatal. 

Diagnosis. — In  children  the  diagnosis  of  peritonitis  is  difficult,  and 
in  infants  the  disease  is  often  unrecognized.  The  history  of  an  asso- 
ciated affection  which  might  cause  peritonitis  and  the  physical  signs 
are  the  most  reliable  points  upon  which  to  base  the  diagnosis.  Dis- 
tention of  the  abdomen  and  extreme  rigidity  of  the  abdominal 
muscles,  with  persistent  vomiting  and  severe  constitutional  disturb- 
ances, make  up  a  group  of  signs  and  symptoms  significant  of  acute 
peritonitis;  but  appendicitis  should  always  be  ruled  out,  if  possible, 
by  rectal  examination.  If  this  can  not  be  done,  and  no  other  cause 
for  the  symptoms  can  be  found,  exploratory  laparotomy  is  justifiable. 

Acute  peritonitis  may  be  differentiated  from  typhoid  fever  by  its 
shorter  and  more  acute  course,  by  the  relative  severity  of  the  symp- 
toms, and  by  the  Widal  reaction.  Intussusception  may  resemble 
peritonitis,  but  it  can  be  differentiated  by  the  absence  of  fever  and 
the  bloody,  mucous  stools  which  result  from  invagination  of  the  gut. 

Prognosis. — Acute  peritonitis  is  a  fatal  disease  during  infancy,  and 
death  usually  occurs  within  the  first  few  days.  Pneumococcal  peri- 
tonitis and  diffuse  peritonitis  caused  by  the  rupture  of  an  abdominal 
viscus  also  present  an  unfavorable  outlook.  Gonorrheal  peritonitis, 
however,  ends  in  recovery  in  a  great  many  cases.  In  circumscribed 
and  traumatic  peritonitis  recovery  depends  upon  the  severity  of  the 
infection  and  the  time  when  operation  is  performed. 

Treatment. — Surgical  interference  offers  a  better  chance  for  recovery 
in  most  cases  of  acute  peritonitis  than  does  any  other  remedial  measure. 
23 


354  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

]\Iedical  treatment  is  warranted  only  in  those  cases  where  peritonitis 
is  due  to  mild  trauma  or  an  acute  infection,  or  when  it  is  associated 
with  nephritis  or  gonorrheal  vulvovaginitis;  even  in  these  cases,  if 
the  disease  fails  to  respond  to  medication  within  two  days,  laparotomy 
is  justifiable.  Operation  is  always  indicated  when  there  has  been  a 
rupture  of  an  abdominal  viscus,  and  should  be  performed  immediately; 
for  in  diffuse  peritonitis  surgery  avails  but  little  if  the  condition  has 
persisted  for  several  days.  Medical  treatment  of  peritonitis  consists, 
for  the  most  part,  in  the  relief  of  pain  and  in  keeping  the  intestines  at 
rest.  The  child  should  be  kept  in  Fowler's  position  and  cold  applied 
to  the  abdomen  for  the  first  few  days  while  the  acute  inflammatory 
symptoms  persist. 

If  one  feels  sure  that  there  is  no  danger  of  perforation  of  the  intes- 
tines, a  thorough  purge  of  |  to  2  drams  of  magnesium  sulphate  should 
be  given.  Nothing  should  be  taken  by  mouth  until  vomiting  ceases; 
but  the  child  may  be  allowed  to  suck  cracked  ice  if  the  mouth  is 
parched.  After  the  first  three  or  four  days  warm  applications,  turpen- 
tine stupes,  and  poultices  may  be  put  on  the  abdomen,  and  the  child 
be  given  whiskey  or  brandy  in  5-  to  20-drop  doses  at  frequent  inter- 
vals during  the  day.  So  long  as  the  stomach  rejects  food,  nourish- 
ment may  be  furnished  by  means  of  nutrient  enemata;  but,  as  the 
patient's  condition  improves,  the  breast-fed  infant  may  resume  its 
nursing  and  the  bottle-fed  baby  be  given  small  quantities  of  a  weak 
milk  mixture,  gruel,  or  broth. 

When  the  temperature  runs  very  high  the  child  may  be  sponged  with 
tepid  water  or  rubbed  with  alcohol.  If  tympanites  becomes  severe, 
a  long  rectal  tube  may  be  inserted  into  the  bowel  and  allowed  to 
remain  there  for  several  hours.  If  stimulation  is  indicated,  champagne 
or  whiskey  in  5-  to  20-drop  doses  should  be  given  at  frequent  intervals, 
and  strychnine  sulphate,  grain  -j^-q  to  grain  2^0,  or  camphorated  oil, 
1  to  5  drops,  may  be  administered  hypodermically.  The  intestines 
may  be  kept  immobile  by  hypodermic  injections  of  morphine  sulphate, 
grain  uV  to  -jV.  combined  with  atropine  sulphate,  grain  ttVo"  to  j}o; 
the  morphine  thus  given  will  also  alleviate  the  pain. 

In  addition  to  these  immediate  measures,  much  can  be  done  to 
improve  the  general  condition  of  the  child  by  giving  it  good  hygienic 
care,  plenty  of  fresh  air,  and  by  sending  it  away  to  the  seashore  or 
country  during  convalescence. 

The  treatment  of  circumscribed  peritonitis  is  essentially  surgical, 
and  consists  of  incision  and  drainage,  followed  by  the  tonic  measures 
outlined  above. 

CHRONIC   PERITONITIS. 

Chronic  peritonitis  which  is  not  caused  by  the  tubercle  bacillus  is 
of  such  extreme  rarity  during  childhood  that  its  occurrence  is  doubted 
by  various  competent  authorities.  This,  however,  applies  only  to 
diffuse  inflammation  of  the  peritoneum,  for  localized  chronic  peri- 
tonitis may  accompany  disease  of  any  of  the  abdominal  viscera. 


CHRONIC  PERirONITIS  355 

Etiology. — The  exatt  cause  of  this  form  of  chronic  })eritonitis  is 
never  clear,  but  it  may  follow  measles,  rheumatism,  exposure,  or 
injury.  The  visceral  layer  of  peritoneum  becomes  inflamed,  A\hile 
the  organ  which  it  covers  becomes  diseased,  and  circumscribed  peri- 
tonitis of  chronic  type  may  follow  appendicitis.  Chronic  non-tuber- 
culous peritonitis  usually  occurs  after  the  fifth  year. 

Pathology. — Chronic  peritonitis  may  be  either  localized  or  diffuse, 
serous  or  fibrinous.  The  serous  form,  or  peritonitis  with  ascites,  is 
characterized  by  the  accumulation  of  a  large  quantity  of  straw-colored 
fluid  within  the  peritoneal  cavity.  There  is  only  a  relatively  small 
amount  of  fibrinous  exudate,  and  few  adhesions  are  found.  This 
picture  is  far  difterent  from  that  of  fibrinous,  dry,  or  proliferative 
chronic  peritonitis  in  which  the  abdominal  cavity  contains  little  fluid, 
but  the  intestines  are  covered  with  fibrin,  and  bound  down  and 
matted  together  by  fibrous  adhesions.  In  chronic  localized  peritonitis 
there  is  an  increase  in  fibrous  tissue  over  the  serous  covering  of  an 
abdominal  viscus  or  about  an  area  of  preceding  inflammation  within 
the  peritoneal  cavity — for  example,  appendicitis  or  salpingitis. 

Symptoms. — The  symptoms  of  chronic  peritonitis  come  on  most 
insidiously.  Enlargement  of  the  abdomen  is  usually  the  first  percep- 
tible sign  of  disease  within  the  abdominal  cavity,  although  there 
may  have  been  gradual  loss  of  weight  and  strength,  and  indefinite 
and  vague  symptoms,  such  as  slight  pain  and  tenderness  of  the 
abdomen.  Dyspepsia  usually  precedes  the  collection  of  ascitic  fluid. 
The  appetite  is  generally  poor;  the  bowels  are  alternately  constipated 
and  loose.  There  is  usually  slight  fever,  highest  in  the  evenmg,  and 
the  child  has  secondary  anemia  from  malassimilation  and  indigestion. 
In  some  cases  there  is  marked  disturbance  of  the  general  nervous 
system,  but,  as  a  rule,  convulsions  do  not  occur. 

On  inspection,  in  ascitic  cases,  the  abdomen  usually  appears  to  be 
enlarged  and  distended,  and  a  fluctuation  wave  can  be  detected.  The 
area  of  flatness  on  percussion  will  be  found  to  change  with  change  in  post- 
ure, and  its  exact  extent  varies  according  to  the  amount  of  fluid  present. 

In  dry,  or  plastic,  peritonitis,  occurring  in  thin  or  emaciated  chil- 
dren, the  greatly  thickened  and  rolled-up  omentum  may  sometimes 
be  palpated.  Chronic  non-tubercular  peritonitis  runs  a  very  irregular 
course  with  alternating  periods  of  relapse  and  improvement;  but  in 
many  cases  the  fluid  is  slowly  absorbed,  and  permanent  recovery 
usually  follows. 

Diagnosis. — The  most  important  point  in  the  diagnosis  of  chronic 
non-tubercular  peritonitis  in  a  child  is  the  presence  of  ascitic  fluid 
in  the  abdomen  with  absence  of  any  disease  of  the  heart,  liver,  or 
kidneys,  and  no  demonstrable  tuberculous  lesion.  Tuberculosis  must 
always  be  excluded  in  these  cases,  although  this  exclusion  is  invariably 
an  extremely  difficult  task. 

Failure  to  find  a  tuberculous  lesion  in  other  parts  of  the  body  is  not 
conclusive  evidence  against  tuberculosis,  neither  is  a  negative  von 
Pirquet  reaction,    IMoreover,  examination  of  the  ascitic  fluid  for  the 


356  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

tubercle  bacillus  is  of  little  value  in  determining  its  presence,  since  it 
is  often  impossible  to  find  it  in  known  tubercular  peritonitis.  But 
when,  in  a  given  case,  all  of  these  determining  factors  are  negative 
and  when  guinea-pig  inoculation  with  the  ascitic  fluid  also  fails  to 
give  a  tuberculous  reaction,  one  is  justified  in  pronouncing  the  case 
non-tubercular. 

Prognosis. — ^The  prognosis  of  chronic  non-tubercular  peritonitis  is 
more  favorable  in  the  child  than  in  the  adult,  and  a  number  of  cases 
end  in  complete  recovery.  There  is  always,  however,  the  danger 
of  death  from  an  intercurrent  infection  or  from  extreme  debility  and 
exhaustion.  The  prognosis  should  be  guarded  in  every  case,  because 
of  the  difficulty  of  definitely  excluding  tuberculosis. 

Treatment. — Rest  in  bed  and  a  carefully  regulated  and  nourishing 
diet  should  be  insisted  upon.  The  child  should  also  be  given  tonics, 
such  as  the  syrup  of  the  iodide  of  iron,  10  to  30  drops,  tincture  of  nux 
vomica,  2  to  5  drops,  or  cod-liver  oil  in  teaspoonftil  doses  after  meals; 
but  the  physician  should  watch  to  see  that  this  medication  does  not 
impair  the  appetite.  The  bowels  must  be  regulated  by  the  adminis- 
tration of  fluidextract  of  cascara  sagrada  (aromatic),  15  to  40  drops, 
or  the  compound  syrup  of  rhubarb,  |  to  1  dram.  If  the  absorption 
of  the  ascitic  fluid  is  very  sloW,  saline  cathartics,  such  as  either  mag- 
nesium sulphate  or  Rochelle  salts,  ^  to  1  dram,  should  be  emploj^ed 
routinely. 

When  these  measures  fail,  and  the  accumulation  of  fluid  becomes 
so  great  as  to  cause  discomfort,  the  abdomen  should  be  tapped  with 
a  trocar  and  the  fluid  slowly  withdrawn.  If  it  rapidly  reaccumulates 
after  each  tapping,  great  improvement,  and  sometimes  recovery,  can 
be  brought  about  merely  by  opening  the  abdomen  and  washing  out 
the  peritoneal  cavity  with  warm  normal  saline  solution. 

ASCITES. 

Ascites  is  an  accumulation  of  serum  in  the  peritoneal  cavity.  It 
is  usually  due  either  to  obstruction  of  the  portal  circulation  or  inflam- 
mation of  the  peritoneum,  although  a  dropsical  condition  of  the 
peritoneum  with  no  apparent  cause  also  occurs,  and  is  more  common  in 
children  than  in  adults. 

Ascitic  fluid  is  usually  clear,  straw-colored,  alkaline  in  reaction, 
with  a  specific  gravity  of  1010  to  1015;  under  the  microscope  it  is 
found  to  contain  leukocytes,  red  corpuscles,  endothelium,  fat  cells, 
and  cholesterin  crystals.  When  ascites  is  due  to  malignancy  or  to 
tuberculous  peritonitis  the  serum  may  be  blood-stained,  and  it  is 
occasionally  also  bile-stained.  In  chylous  ascites  the  accumulated 
fluid  has  a  milky  appearance,  and  contains  fat  droplets,  sugar,  and  a 
few  lymphocytes. 

Etiology. — Ascites  is  frequently  associated  with  general  edema  in 
cases  of  nephritis,  cardiac  disease,  chronic  pleurisy,  pernicious  anemia, 
and  leukemia.    It  is  also  a  prominent  symptom  in  most  cases  of  peri-. 


ASCITES  357 

tonitis  in  children,  especially  those  due  to  tuberculous  infection.  A 
common  cause  is  portal  obstruction,  which  may  be  the  result  either 
of  diseases  of  the  liver,  such  as  cirrhosis,  syphilis,  lardaceous  disease, 
or  hepatic  tumors,  or  of  interstitial  pneumonia,  thrombosis  of  the 
portal  vein,  pressure  of  abdominal  tumors,  or  obstruction  of  the  vena 
cava  by  enlarged  retroperitoneal  lymph  nodes. 

Simple  dropsy,  or  that  form  without  apparent  cause,  is  in  all  prob- 
ability in  most  instances  due  to  subacute  peritonitis.  Chylous  ascites 
is  due  to  obstruction  of,  or  injury  or  ulceration  along  the  thoracic 
duct;  it  is  sometimes  observed  in  association  with  tuberculosis  of  the 
mesenteric  glands. 

Symptoms. — The  symptoms  of  ascites  are  very  mild  and  usually 
imperceptible  until  the  accumulation  of  fluid  is  large  enough  to  cause 
a  sensation  of  weight  and  pressure  in  the  lower  abdomen.  As  the 
amount  of  fluid  increases,  the  symptoms  due  to  pressure  become 
more  decided,  and  constipation,  dragging  pains  in  the  loins,  dyspnea, 
and  frequent  micturition  result. 

At  this  stage  the  presence  of  fluid  in  the  abdomen  is  quite  obvious, 
and  in  some  cases  the  abdomen  becomes  enormously  large,  the 
enlargement  being  symmetrical.  The  superficial  veins  in  the  skin 
about  the  umbilicus  are  distended  and  prominent,  and  a  fluctuation 
wave  may  easily  be  detected.  On  percussion  there  is  flatness  in  the 
flanks,  also  tympany  over  the  centre  of  the  abdomen  while  the  child 
lies  on  its  back,  with  alteration  in  the  areas  of  flatness  and  tympany 
on  change  of  posture.  The  liver,  spleen,  and  even  the  heart  are 
pressed  upon  by  the  accumulated  fluid,  and  finally  displaced. 

Diagnosis. — The  diagnosis  of  ascites  should  be  based  upon  a  history 
of  one  of  the  causative  factors  that  have  been  mentioned,  together 
with  the  physical  signs  and  symptoms  of  an  unsacculated  accumula- 
tion of  fluid  within  the  peritoneal  cavity.  On  seeking  in  a  given  case 
to  find  the  cause  of  ascites,  examination  of  the  heart,  blood,  and  urine 
will  quickly  show  whether  cardiac  disease,  anemia,  or  nephritis  is  the 
underlying  cause,  while  removal  of  the  ascitic  fluid  followed  by  deep 
abdominal  palpation  will  often  reveal  the  presence  of  a  tumor  in  those 
cases  due  to  portal  obstruction  by  a  neoplasm. 

Abdominal  cysts  may  grow  so  large  that  they  closely  simulate 
ascites,  hence  such  conditions  as  hypernephroma,  ovarian  cysts,  and 
hydatid  disease  of  the  liver  must  always  be  excluded.  The  protuberant 
abdomen  seen  so  often  in  children  with  chronic  intestinal  indigestion, 
rachitis,  or  marasmus,  sometimes  suggests  ascites;  but  careful  physical 
examination  will  reveal  no  shifting  flatness  or  tympany  on  change  of 
posture,  no  fluctuation  wave,  and  the  apparent  distention  of  the 
abdomen  will  disappear  when  the  child  lies  down.  Chylous  ascites 
can  be  diagnosed  only  when  some  of  the  ascitic  fluid  has  been  with- 
drawn from  the  abdominal  cavity  and  examined. 

Prognosis. — Ascites  is  but  a  symptom,  not  a  disease;  therefore  the 
prognosis  depends  upon  the  underlying  factor.  Except  in  idiopathic 
or  simple  dropsy,  the  outlook  is  generally  unfavorable. 


358  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

Treatment. — ()b\i()iisly  the  most  essential  point  in  em'ing  aseites 
is  to  remoN'e  the  eause,  all  other  measnres  being  designed  merelj^ 
to  alleviate  the  symptoms  caused  by  the  presence  of  the  fluid  within 
the  abdominal  cavity.  The  child  should  be  placed  on  a  light  nutri- 
tious diet  containing  a  high  nitrogen  content,  and  the  liquid  intake 
restricted  as  much  as  possible. 

Hydragogue  cathartics,  such  as  magnesium  sulphate,  dose  20  to  60 
grains,  or  powdered  jalap,  dose  1  to  3  grains,  and  diuretics  such  as 
potassium  bitartrate,  5  to  20  grains,  or  digitalis  leaves  powdered,  tV 
to  1  grain,  or  powdered  squills,  2T  to  |  of  a  grain,  should  be  given 
in'  order  to  drain  the  tissues  of  fluid  and  promote  the  absorption  of 
the  ascitic  serum  in  the  peritoneum.  Tonics,  such  as  the  syrup  of 
the  iodide  of  iron,  dose  10  to  30  minims,  or  the  saccharated  carbonate 
of  iron  in  y-  to  1-grain  doses,  are  speciaelly  beneficial  in  ascites  due  to 
anemia,  or  in  so-called  simple  dropsy. 

If,  in  spite  of  the  treatment  above  outlined,  absorption  of  the 
fluid  does  not  take  place  and  the  pressure  symptoms  become  worse, 
the  abdomen  should  be  tapped  and  the  serum  withdrawn  slowly 
through  a  trocar.  Several  hours  should  be  consumed  in  completely 
draining  off  the  ifuid,  and  the  abdomen  should  be  tightly  bandaged 
during  and  after  its  removalin  order  to  prevent  such  a  sudden  and 
great  fall  in  intra-abdominal  pressure  as  would  produce  harmful 
consequences. 

INGUINAL   HERNIA. 

Inguinal  hernia  is  not  an  uncommon  affection  in  childhood,  occur- 
ring most  frequently  in  little  boys.  Three  forms  are  recognizable; 
the  congenital,  funicular,  and  infantile.  The  congenital  type  is  that 
in  which  a  loop  of  intestine  forces  its  way  through  the  still  open 
funicular  process,  and  thus  effects  entrance  to  the  scrotum,  where  it 
usually  surrounds  the  testicle. 

In  the  funicular  type  the  tunica  vaginalis  is  shut  off  from  the  funic- 
ular process  above  the  testicle,  so  that  the  hernia  occupies  the 
funicular  canal,  but  does  not  envelop  the  testicle.  The  infantile,  or 
encysted,  form  is  very  rare,  and  can  be  diagnosed  only  at  operation. 
The  intestine,  encased  in  a  pouch  of  peritoneum,  forces  its  way  into 
the  funicular  process  and  descends,  although  this  canal  is  closed  above 
and  open  below. 

Etiology. — Hernia  may  exist  at  birth  or  it  may  develop  as  the  child 
grows  older  and  begins  to  lead  an  active  life;  but  in  children  it  is 
always  regarded  as  a  congenital  condition.  It  usually  occurs  on  the 
right  side,  but  both  sides  may  be  involved,  and  'thus  give  rise  to  a 
double  inguinal  hernia.  Boys  are  more  frequently  affected  with  hernia 
than  girls  because  of  the  presence  in  boys  of  the  inguinal  canal,  which 
is  a  weak  spot  made  by  the  testicle  in  its  descent  to  the  scrotum. 

The  infant  is  predisposed  to  hernia  because  of  the  relatively  short 
and  direct  course  of  the  inguinal  canal,  which  allows  easy  passage  of 
the  gut  through  the  internal  ring  if  this  inner  opening  is  not  entirely 


INGUINAL  HERNIA  359 

closed,  or  if  the  peritoneum  at  this  point  is  weak  or  lax.  Femoral 
hernia,  on  the  other  hand,  is  very  rare  in  children  because  of  the 
proximity  of  the  pubic  spine,  the  anterior  spine  of  the  ilium,  and  Pou- 
part's  ligament,  which  in  the  child  lie  so  close  together  that  there  is 
really  insufficient  space  for  a  hernia  to  form.  It  is  more  common 
in  girls  than  in  boys. 

Pathology. — The  hernial  sac  usually  contains  loops  of  the  small 
intestine,  and  only  occasionally  is  the  omentum  found  within  it. 

Symptoms. — In  most  cases  the  only  symptom  is  the  presence  of 
a  tumor  in  the  inguinoscrotal  region.  This  tumor  becomes  smaller 
when  the  child  lies  down,  and  again  enlarges  when  the  upright  position 
is  assumed,  or  whenever  intra-abdominal  pressure  is  increased  by 
crying  or  coughing.  Upon  examination  the  external  ring  is  found  to 
be  enlarged,  an  impulse  is  transmitted  to  the  tumor  during  coughing, 
and  the  mass  on  being  manipulated  and  pushed  back  into  the  abdomen 
makes  a  gurgling  sound.  The  entire  scrotum  may  be  filled  by  the 
tumor,  so  that  it  is  difficult  to  palpate  the  testicles,  but  they  can 
usually  be  found  above  and  behind  the  coils  of  intestine.  It  is  important 
that  both  testicles  be  located  in  order  to  eliminate  the  possibility  of 
an  undescended  testicle.  When  an  inguinal  hernia  occurs  in  girls, 
the  tumor  occupies  one  of  the  labia  majora. 

Diagnosis. — The  diagnosis  of  inguinal  hernia  is  more  perplexing  in 
children  than  in  adults  because  of  the  possibility  of  mistaking  it  for 
other  conditions  which  may  produce  a  tumor  in  this  location  during 
childhood,  also  because  of  various  affections  which  may  coexist  with 
hernia,  such  as  a  cyst  of  the  spermatic  cord,  a  hydrocele,  or  an 
undescended  testicle.  Congenital  hydrocele,  which  is  comparatively 
common  in  children,  presents  the  following  differentiating  features: 

Hernia.  Hydrocele. 

Reducible,  accompanied  by  gurgling  on  Irreducible,  or  slowlj-  so,  with  no 

reduction.  gurgling  sounds. 

Dulness  or  tympany  on  percussion.  Flat  on  percussion. 

Increase  in  size  on  crying  and  coughing.  No  change  in  size. 

Impulse  on  coughing.  No  impulse. 

Opaciue.  Translucent. 

Encysted  hydrocele  of  the  cord  presents  the  same  differentiating 
features  as  congenital  hydrocele;  but,  owing  to  its  movability,  it 
may  be  pushed  into  the  internal  ring  and  an  apparent  reduction  thus 
be  accomplished,  which  is  very  confusing.  The  scrotum  should 
always  be  carefully  examined  in  order  to  determine  the  position  of 
the  testicles;  for  if  they  can  be  located  in  this  manner  undescended 
testicle  can  be  ruled  out.  If  the  testicle  is  not  found  on  that  side  of 
the  scrotum  in  which  there  is  a  tumor,  the  hernia  is  probably  compli- 
cated by  an  undescended  testicle,  and  on  examination  of  the  mass  the 
testicle  will  be  felt  as  a  firm  hard  tumor  which  is  tender  and  painful 
on  pressure.  There  is  no  pain  or  tenderness  associated  with  uncom- 
plicated hernia,  and  the  tumor  is  elastic  and  soft. 

Femoral  hernia  can  be  easily  distinguished  from  the  inguinal  variety 


360  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

by  the  location  of  the  tumor  just  beneath  the  saphenous  opening, 
with  its  origin  from  the  outer  side  of  the  pubic  spine;  while  the  origin 
of  inguinal  hernia  is  from  the  inner  side  of  the  spine  of  the  pubic  bone. 
Enlarged  inguinal  glands^  while  sometimes  giving  rise  to  a  tumor 
resembling  that  of  hernia,  are  easily  differentiated,  for  on  palpation 
they  are  found  to  be  hard,  firm,  and  non-reducible;  they  transmit 
no  impulse;  and  are  accompanied  by  enlargement  of  the  whole  chain 
of  glands  in  this  region. 

Complications. — In  addition  to  other  congenital  conditions,  such  as 
undescended  testicle  and  hydrocele,  hernia  may  be  complicated  by 
obstruction  of  the  bowels  caused  by  strangulation  of  the  loop  of  intes- 
tine caught  within  the  hernial  sac.  This  occurrence,  however,  is  quite 
rare  in  children  because  of  the  elasticity  of  the  tissues  of  the  inguinal 
canal;  but,  strange  as  it  may  seem,  it  happens  more  frequently  in 
infants  than  in  older  children.  In  the  child  the  symptoms  of  stran- 
gulation are  very  acute;  there  is  sudden  pain,  with  vomiting  and 
absolute  constipation  after  the  fecal  contents  of  the  bowel  below  the 
obstruction  have  been  passed.  The  hernia  is  irreducible  and  very 
painful;  the  child  lies  with  the  leg  on  the  affected  side  drawn  up  to 
the  abdomen. 

Prognosis. — The  prognosis  in  micomplicated  hernia  in  the  child  is 
very  favorable,  and  in  the  majority  of  cases  recovery  ensues  if  properly 
fitting  appliances  are  obtained  and  worn  to  keep  the  hernia  from  com- 
ing down  into  the  inguinal  canal. 

Treatment. — Operation  for  the  ciu*e  of  hernia  is  necessary  only  in 
older  children;  for,  during  the  first  few  years  of  life,  the  application 
of  a  truss,  which  must  be  worn  continuously  day  and  night,  will 
generally  effect  a  cure.  If  the  wearing  of  a  truss  is  successful  it 
will  bring  about  obliteration  of  the  hernial  sac,  and  close  the  ring 
within  a  year,  so  that,  at  the  end  of  this  period,  the  pressure  on  the 
ring  can  be  removed  and  the  tumor  will  not  appear.  But  the  truss 
should  always  be  worn  for  at  least  six  months  after  this  time  in  order 
to  prevent  recm-rence. 

When  a  child  is  wearing  a  truss,  the  physician  in  charge  of  the 
case  should  instruct  those  in  attendance  to  see  that  the  pressure  upon 
the  hernial  opening  is  never  relaxed;  for  if  the  hernia  should  reappear 
during  bathing,  and  this  should  happen  frequently,  it  will  indefinitely 
postpone  cure.  Care  should  also  be  taken  to  see  that  the  skin  beneath 
the  truss  pad  does  not  become  irritated  or  excoriated,  and  to  this 
end  special  effort  must  be  made  to  keep  the  skin  in  this  region  dry. 
As  the  child  grows,  the  truss  should  frequently  be  made  larger  to 
accommodate  the  increasing  size  of  the  child;  but  it  should  not  be 
worn  indefinitely. 

After  the  second  year  the  prospect  of  cure  by  non-operative  means 
diminishes  greatly,  so  that  operation  is  advisable  if  the  condition 
persists  without  improvement.  Owing  to  the  difficulty  of  properly 
fitting  a  truss  for  femoral  hernia,  operation  is  advisable  in  children 
as  soon  as  the  patient's  general  condition  will  allow  it.     If  inguinal 


PROCTITIS  361 

hernia  becomes  incarcerated  or  strangulated,  operation  is  imperative, 
and  should  be  performed  immediately. 

The  results  of  operation  in  uncomplicated  hernise  are  so  favorable 
that  it  is  unquestionably  the  surest  and  safest  mode  of  cure,  provided 
the  child  is  old  enough  and  strong  enough  to  survive  the  operation. 
In  children  suffering  from  hernia  the  bowels  should  be  kept  regular 
before  and  after  operation,  and  after  a  cure  has  been  effected,  either 
by  operation  or  non-operative  measures,  active  exercise  should  be 
prohibited  for  months,  in  order  to  prevent  a  possible  recurrence. 

Strangulated  or  incarcerated  hernia  calls  for  immediate  reduction 
by  taxis  and  manipulation,  or  by  operation.  In  attempting  to  reduce 
a  strangulated  hernia,  which  is  an  easier  procedure  in  the  child  than 
in  later  life,  the  child  should  first  be  placed  in  a  warm  bath  to  relax 
the  muscles,  and  then  a  few  drops  of  ether  be  administered.  If  the 
contents  of  the  hernial  sac  can  not  be  pushed  back,  immediate  opera- 
tion is  demanded,  the  nature  and  extent  of  w^hich  will  depend  upon 
the  condition  of  the  strangulated  intestine.  If  gangrene  is  present, 
resection  is  advisable,  and  in  older  children  the  shock  of  resection  is 
frequently  borne  quite  well,  although  it  is  usually  fatal  in  infants. 


DISEASES   OF  THE   RECTUM  AND  ANUS. 


PROCTITIS. 

Proctitis,  or  inflammation  of  the  rectum,  is  not  uncommon  during 
childhood,  and  may  be  either  primary  or  secondary.  Of  the  simple 
varieties  the  catarrhal  is  the  most  common,  and  the  membranous  and 
ulcerative  types  are  the  most  infrequent.  The  specific  form  is  rare; 
it  is  spread  from  the  genitalia  in  cases  of  gonorrheal  vaginitis  and 
diphtheritic  vulvovaginitis. 

Etiology. — Among  the  primary  causes  of  proctitis  must  be  included 
trauma  (although  this  is  rare),  threadworms,  the  use  of  drastic  pur- 
gatives, and  rough  manipulation  of  thermometers  and  sjTinge  nozzles 
when  inserted  within  the  rectum.  The  prolonged  use  of  soap  or 
glycerin  suppositories  may  also  produce  irritation  and  inflammation 
of  the  rectum.  Proctitis  occurs  secondarily  in  cases  of  gastro-enteritis, 
dysentery,  prolapse  of  the  rectum,  and  rectal  polypi. 

Except  when  it  accompanies  general  diphtheritic  infection,  the 
membranous  form  is  more  often  due  to  the  streptococcus  than  to  the 
Klebs-Loeffler  bacillus;  while  gonorrheal  proctitis  is,  in  the  majority 
of  cases,  caused  by  a  spreading  of  the  profuse  discharge  from  the 
vagina  backward  into  the  anus,  but  may  also  be  produced  by  careless 
handling  of  thermometers  and  sjTinge  nozzles. 

Pathology. — In  catarrhal  proctitis  the  mucous  membrane  is  swollen 
and  hyperemic,  and  there  is  an  exudation  of  blood-stained  mucus. 
The  ulcerative  form  is  but  a  more  advanced  stage  of  the  catarrhal 


362  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

type,  and  is  uiarkrd  b\"  the  formation  of  laruv  superficial  ulcers  scat- 
tered throughout  the  rectum.  Fohicular  ulceration  of  the  rectum  is 
also  occasionally  seen  in  association  with  follicular  ulcerative  colitis; 
in  this  type  the  ulcerations,  while  small,  are  quite  deep,  extending  far 
down  to  the  muscular  coat  of  the  bowel. 

In  membranous  proctitis  many  superficial  ulcerations  form;  they 
are  covered  wdth  a  grayish-white  membrane  w^hich  is  very  tenacious 
and  leaves  a  raw,  bleeding  surface  when  removed.  Gonorrheal  infec- 
tion of  the  rectum  gives  rise  to  a  severe  catarrhal  inflammation,  dis- 
tinguished by  an  excessive  purulent  secretion. 

Symptoms. — Among  these,  rectal  tenesmus  is  the  most  prominent, 
and  is  extremely  severe  during  defecation,  the  pain  lasting  a  con- 
siderable time  after  each  bowel  movement.  The  child  is  usually 
constipated,  but  there  are  frequent  discharges  from  the  rectum  of 
bloody  mucus  which  may  or  may  not  be  mixed  with  feces.  The  stools 
contain  shreds  of  mucus  and,  in  the  diphtheritic  type,  sometimes 
casts  of  the  rectum.  In  ulcerative  proctitis  much  blood  is  usually 
passed  by  the  bowel.  In  gonorrheal  proctitis  the  discharge  from  the 
rectum  is  distinctly  purulent  and,  if  examined  microscopically,  may 
be  found  to  contain  the  gonococcus.  Prolapse  of  the  rectum  quite 
often  accompanies  the  condition  as  a  result  of  the  straining  and 
tenesmus  at  stool. 

Treatment. — The  child  suffering  with  proctitis  should  be  put  to 
bed,  and  kept  upon  a  nourishing  liquid  diet  which  will  not  cause  con- 
stipation. If  necessary,  the  stools  can  be  kept  loose  by  the  adminis- 
tration of  mild  laxatives,  such  as  the  s\Tup  of  rhubarb,  in  20-  to  60- 
drop  doses,  or  milk  of  magnesia,  1  to  2  teaspoonfuls  at  a  dose.  Pain 
may  be  relieved  by  the  use  of  suppositories  of  ^V  ^o  i  grain  of  opium 
or  2V  to  ^  grain  of  cocaine,  or  by  painting  the  mucous  membrane  of 
the  rectum  with  cocaine  solution. 

Sweet  oil,  olive  oil,  saline  solutions,  lime-water,  boric  acid,  and 
potassium  permanganate  may  all  be  used  for  injection  in  the  catarrhal 
form  of  the  disease;  but  care  should  be  taken  not  to  further  irritate 
the  already. inflamed  rectum. 

In  the  ulcerative  form  a  w'eak  astringent,  such  as  f  of  1  per  cent,  of 
silver  nitrate  solution,  is  very  effectual,  while  in  gonorrheal  proctitis 
injections  of  antiseptic  solutions,  such  as  tincture  of  iodine,  a  half- 
dram  to  a  pint  of  water,  or  1  to  2000  sih'er  nitrate  solution,  or  a  1 
per  cent,  solution  of  protargol  or  witchliazel,  are  all  indicated.  In 
diphtheritic  proctitis  the  child  should  be  given  large  doses  of  anti- 
toxin in  addition  to  the  local  treatment. 

PROLAPSE  OF  THE  RECTUM  fPROCIDENTIA  RECTI). 

Prolapse  of  the  rectum  may  be  either  partial  or  complete,  according 
to  whether  the  mucous  membrane  alone  or  the  entire  rectal  wall  pro- 
trudes from  the  anus.  Partial  prolapse,  or  prolapse  of  the  anus,  as 
it  is  sometimes  called,  is  due  to  relaxation  of  the  mucous  membrane 


PROLAPSE  OF   THE  RECTUM 


3r>3 


which,  to  a  certain  extent,  becomes  detache*.!  from  the  mnsculai'  coat 
of  the  rectum  underlying  it,  and  is  everted  by  the  straining  at  stool. 
It  may,  perhaps,  return  to  its  place  after  each  movement  of  the  bowels, 
and  the  affection  usually  shows  a  tendency  to  spontaneous  cure. 

A  predisposition  to  total  prolapse  may  be  accounted  for  by  the 
almost  vertical  position  of  the  rectum  during  infancy  and  early  child- 
hood, and  by  its  weak  attachments  which  fail  to  hold  it  in  place. 
Constipation  and  diarrhea,  as  well  as  dysentery  which  causes  severe 
tenesmus  and  straining,  are  the  most  frequent  causes  of  rectal  prolapse, 
owing  to  the  increased  abdominal  pressure  they  produce. 

Other  conditions,  such  as  fecal  concretions,  rectal  polypi,  vesical 
calculi,  and  irritation  of  the  rectum,  bladder,  or  genitalia  from  other 
causes,  may  be  contributory  factors.  Pertussis  may  produce  it 
because  of  the  increased  abdominal  pressure  during  paroxysms  of 


Fig.  31. — Procidentia  recti;    cretin  eight  years  old. 


coughing.  Rectal  prolapse  occurs  most  commonly  in  children  under 
three  years  of  age,  especially  if  they  are  undernourished,  weak,  or 
anemic,  and  is  not  infrequent  in  rachitic  children  (Fig.  31). 

Symptoms. — In  cases  of  prolapse  of  the  anus  inspection  reveals  an 
everted  mass  of  mucous  membrane  which  may  be  covered  with  mucus 
and  blood,  and  surrounds  the  anal  orifice.  It  has  a  central  aperture, 
and  is  easily  reducible.  Prolapse  of  the  rectum  forms  a  much  longer 
and  thicker  mass,  with  an  orifice  in  the  centre  of  the  distal  end.  The 
mucous  membrane  is  at  first  bluish-red  in  color,  and  shows  marked 
congestion. 

Later,  if  the  prolapse  is  not  reduced,  ulceration  may  develop,  pain 
become  severe,  and  the  tumor  swells  and  bleeds  constantly.  Reduction 
is  now  difficult;  but  if  the  case  is  seen  just  after  prolapse  has  occurred 
it  can  usually  be  corrected  merely  by  manipulation. 


364  DISEASES  OF   THE  GASTRO-INTESTINAL  TRACT 

Diagnosis. — Actual  prolapse  of  the  rectum  is  easily  diagnosed  by 
inspection;  but  sometimes  rectal  polypi  and  intussusception  may 
simulate  a  prolapse,  in  which  case  the  examining  finger  can  be  inserted 
between  the  tumor  and  the  rectal  wall,  which  obviously  would  be 
impossible  in  rectal  prolapse. 

Treatment. — In  mild  cases,  the  tumor  can  usually  be  replaced  by 
simple  manipulation,  and  this  should  be  done  after  every  bowel  move- 
ment which  brings  on  a  prolapse.  A  suppository  of  tannic  acid,  2 
grains,  or  some. other  astringent,  should  be  inserted  within  the  rectum 
as  soon  as  the  prolapse  has  been  reduced;  a  cold-water  douche  after 
each  bowel  evacuation  will  strengthen  the  muscular  tone  of  the 
rectum. 

Severe  cases  of  prolapse  require  the  application  of  cold  to  the 
swollen  and  inflamed  tumor,  and  in  some  instances  it  may  be  found 
necessary  to  administer  a  few  whiffs  of  chloroform  to  relax  the  con- 
tracted muscles  before  the  rectum  can  be  pushed  back  into  position. 
The  child  should  be  laid  upon  the  lap,  face  down,  with  the  legs  higher 
than  the  buttocks,  while  reduction  is  being  accomplished,  and  after 
the  rectum  has  been  replaced  the  buttocks  should  be  held  together 
by  strips  of  adhesive  plaster  in  order  to  prevent  another  prolapse. 
In  severe  cases  rest  in  bed  is  advisable,  and  should  be  insisted  upon 
until  marked  improvement  takes  place.  Even  in  mild  cases  the  child 
should  always  lie  down  before  his  bowels  move. 

In  addition  to  these  immediate  measures,  much  can  be  done  to 
benefit  these  children  by  ascertaining  and  removing  the  cause  of  the 
prolapse,  whether  it  be  constipation,  diarrhea,  intestinal  parasites, 
rectal  polypi,  or  any  other  source  of  irritation  which  increases  intra- 
abdominal pressure  or  straining  at  stool.  The  bowels  should  be 
regulated  and  kept  slightly  loose.  An  effort  should  also  be  made  to 
build  up  the  child's  general  health  by  a  nourishing  diet,  improved 
surroundings,  and  other  hygienic  measures. 

Under  this  treatment  the  ordinary  case  of  prolapsed  rectum  will 
recover  unless  the  sphincter  ani  has  altogether  lost  its  tonicit}^,  when 
operation  will  be  necessary.  But  surgical  procedures  which,  in  the 
adult,  are  attended  by  excellent  results  may  be  much  too  severe  for 
the  child;  therefore,  as  a  general  rule,  we  should  choose  the  simplest 
operation  which  will  give  results.  Thus,  fixation  of  the  rectum  at  a 
higher  level  is  too  formidable,  hence  is  contraindicated,  and  scarifica- 
tion of  the  mucous  membrane  with  the  actual  cautery  or  amputation 
of  the  prolapsed  portion  of  rectum  should  be  chosen  instead. 

RECTAL   POLYPI. 

These  growths  in  the  rectum  are  rarely  found  in  infants,  but  the 
condition  is  not  uncommon  during  later  childhood.  They  are  usually 
pedunculated,  but  may  have  a  sessile  base,  and  consist  merely  of 
hypertrophied  mucous  membrane.  As  a  rule,  there  is  but  one  polypus 
present,  and  that  is  commonly  situated  on  the  posterior  wall  of  the 


FISSURE  IN  ANO  365 

rectum  just  above  the  internal  sphincter.  These  tumors  may  be 
either  adenomata,  myxomata,  or  fibromata.  They  are  hard  and 
firm,  and  are  composed  of  vilU  and  rugae  of  the  mucous  membrane. 
In  exceptional  cases  the  rectum  may  be  nearly  filled  with  small 
tumors. 

Sym.ptoms. — The  most  common  symptoms  of  rectal  polypi  are 
tenesmus,  prolaps^  and  hemorrhage  from  the  bowel.  Pain  is  very 
severe  whenever  the  bowels  move,  and  the  stool  is  covered  with  bright 
red  blood. 

Diagnosis. — ^The  diagnosis  should  be  rnade  only  after  digital  exam- 
ination and  exploration  of  the  rectum  with  a  speculum  and  reflected 
light. 

Treatment. — When  the  growth  is  pedunculated  it  may  be  easily 
ligated  at  the  base  and  snipped  off.  Sessile  tumors  are  quite  difficult 
to  remove,  and  a  rectal  speculum  should  be  used  in  order  to  see  that 
the  ligature  embraces  all  of  the  stump.  After  removal  of  polypi, 
an  opium  suppository  or  iodoform  ointment  should  be  inserted  in 
the  rectum  to  relieve  the  pain.  It  is  dangerous  to  allow  these  growths 
to  remain  in  the  rectum,  since  they  are  apt  to  become  malignant. 

HEMORRHOIDS. 

Children  rarely  suft'er  from  hemorrhoids,  but  either  the  external 
or  internal  variety  may  occasionally  be  observed.  They  are  practically 
never  seen  in  infancy,  but  are  less  rare  as  the  child  advances  beyond 
the  third  year. 

Etiology. — The  most  common  cause  of  these  growths  is  chronic 
constipation. 

Syro.ptom.s. — The  internal  form  of  hemorrhoids  is  the  only  one  likely 
to  be  met  with  in  children,  so  that  usually  no  tumor  is  found  on  inspec- 
tion of  the  anus.  The  only  important  symptoms  are  pain  and  the 
passage  of  stools  containing  bright  red,  unchanged  blood. 

Treatment. — The  bowels  should  be  kept  loose  by  the  administration 
of  cascara  sagrada,  10  to  30  drops,  each  evening,  or  milk  of  magnesia, 
1  to  3  drams.  The  anus  should  be  kept  clean,  and  the  lower  rectum 
flushed  with  salt  solution  twice  a  day,  after  which  an  astringent  oint- 
ment containing  2  per  cent,  of  tannic  acid  may  be  applied,  or  the 
following  solution  may  be  injected  into  the  rectum  each  morning: 

I^ — Acidi  tannici gr-  i.i 

Ichthyoli 5ss 

Alcoholis 3j 

Aqua         q.  s.  ad.  flgiss 

Sig. — Use  as  injection  each  morning. 

FISSURE   IN   ANO. 

Fissure  of  the  anus  is  usually  the  result  of  severe  constipation,  and 
is  caused  by  the  stretching  of  the  anal  mucosa  in  passing  large  hard 
fecal  masses.    In  exceptional  cases  it  is  produced  by  rough  manipula- 


366  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

tion  of  the  nozzle  of  a  syringe  or  rectal  tube,  and  occasionally  it 
is  associated  with  eczema  of  the  anus  and  the  presence  of  intestinal 
parasites. 

Symptoms. — Pain  is  so  extremely  severe  and  agonizing  when  the 
bowels  are  moved  that  the  child  voluntarily  retains  the  feces  within 
the  bowel  as  long  as  possible,  thus  increasing  the  constipation  and 
aggravating  the  condition.  Bright  red  blood  may  appear  upon  the 
diaper  or  in  the  stool. 

Diagnosis. — The  diagnosis  is  made  by  physical  examination,  which 
reveals  in  acute  cases  a  small  narrow  break  at  the  mucocutaneous 
junction,  and  an  ulcerated  area  if  the  fissure  be  chronic, 

Treatro.ent. — The  bowels  should  be  kept  moving  freely  by  the  use 
of  laxatives  to  prevent  the  formation  of  hard  masses  of  feces.  The 
mucous  membrane  should  be  thoroughly  cleansed  every  day  with  a 
mild  antiseptic  solution,  such  as  a  saturated  solution  of  boric  acid, 
and  the  fissure  then  touched  with  a  10  per  cent,  solution  of  nitrate  of 
silver.  Relief  is  often  afforded  by  keeping  the  anus  well  greased  with 
vaseline  or  oxide  of  zinc  ointment  containing  1  per  cent,  of  phenol. 
If  there  is  any  tendency  to  chronicity  the  anus  should  be  forcibly 
dilated  with  the  fingers. 

SPASM   OF   THE   ANUS. 

Spasm  of  the  anus  is  most  commonly  associated  with  fissure  in  ano, 
but  may  happen  also  in  neurotic  children  when  no  organic  lesion  exists. 

Symptoms. — Tenesmus  and  pain  during  defecation  are  the  principal 
symptoms.  Constipation  is  caused  by  the  natural  aversion  of  the 
patient  to  evacuate  the" bowels  because  of  the  pain  which  the  act 
produces.  Examination  of  the  anus  in  these  cases  will  reveal  a 
markedly  contracted  sphincter  ani. 

Treatment. — The  bowels  should  be  regulated  by  the  administration 
of  mild  laxatives,  such  as  aromatic  syrup  of  rhubarb,  |  to  1  fluidram; 
cascara  sagrada,  1  to  2  grains;  or  milk  of  magnesia,  1  to  2  drams. 
Injections  of  olive  or  sweet  oil  also  render  the  lower  end  of  the  rectum 
less  sensitive;  but  care  should  be  taken  not  to  cause  irritation. 

In  some  cases  it  may  be  found  necessary  forcibly  to  dilate  the 
sphincter.  The  following  prescription  will  be  found  valuable  in 
inhibiting  rectal  spasm,  and  is  especially  useful  if  there  is  a  slight 
abrasion  of  the  mucous  membrane  or  a  fissure  in  the  anus: 

I^ — Unguenti  belladonnse, 

Unguenti  hyoscyami aa      3ij 

Petrolati q.  s.  ad.      5j 

Sig. — Apply  freely. 

ANAL   FISTULA. 

Anal  fistulffi  are  rare  during  childhood,  but  may  occasionally  be 
the  sequeltTe  of  proctitis  and  hemorrhoids.  In  many  cases  the  infection 
is  tuberculous.    The  course  of  the  disease  is  usuallv  chronic. 


ISCHIORECTAL  ABSCESS  367 

Symptoms. — The  affection  first  manifests  itself  as  a  small  abscess 
in  the  cellular  tissue  surrounding  the  anus.  Instead  of  forcing  its 
way  to  the  surface  and  rupturing  externally,  this  abscess  burrows  into 
the  surrounding  tissues.  The  openings  of  the  fistula  are  usually  quite 
small,  even  though  the  fistulous  tract  is  long  and  tortuous.  When 
one  opening  is  in  the  rectal  mucous  membrane  and  the  other  on  the 
skin  surface  the  fistula  is  called  a  complete  one. 

A  complete  internal  fistula  is  one  which  has  both  openings  in  the 
mucous  membrane,  and  a  complete  external  fistula  is  one  with  both 
of  its  openings  on  the  skin  surface.  Blind  fistulse  have  but  one  open- 
ing, and  may  be  either  internal  or  external,  according  to  whether  that 
opening  is  on  the  skin  or  in  the  rectum.  External  fistulse  manifest 
themselves  by  the  formation  of  this  opening  on  the  skin  which  does 
not  heal,  and  continually  discharges  pus.  If  the  fistula  is  internal, 
pruritus  often  accompanies  it,  and  is  thought  to  be  due  to  irritation 
of  the  anus  by  the  pus  which  exudes  from  the  orifice  of  the  fistula 
within  the  rectum. 

Diagnosis. — The  subjective  symptoms  are  very  mild,  and  until  pus 
is  detected  oozing  from  one  of  the  orifices  the  existence  of  the  affec- 
tion may  not  even  be  suspected.  If,  however,  such  an  opening  be 
found,  the  diagnosis  is  easily  confirmed  by  inserting  a  probe  and  fol- 
lowing its  course.  In  this  manner,  also,  the  nature  of  the  fistula 
can  be  determined;  or,  better  still,  the  course  and  ending  of  a  fistulous 
tract  can  be  ascertained  by  injecting  hydrogen  peroxide  into  one 
orifice,  and  noting  its  appearance  at  the  other. 

Treatment. — The  treatment  of  fistula  in  ano  is  surgical.  If  the 
fistula  is  complete,  the  entire  length  of  the  tract  should  be  incised  and 
laid  open;  if  incomplete,  it  should  be  converted  into  a  complete  one 
by  artificially  continuing  the  tract  until  it  has  an  internal  opening 
into  the  rectum,  and  then  be  incised.  After  incision  the  pyogenic 
membrane  lining  the  fistulous  tract  should  be  curetted  away,  and  the 
cavity  packed  with  iodoform  gkuze.  By  these  means  a  cure  is  usually 
brought  about,  but  relapses  are  common. 

ISCHIORECTAL    ABSCESS. 

An  ischiorectal  abscess  is  one  which  forms  in  the  ischiorectal  fossa 
midway  betw^een  the  anus  and  the  tuberosity  of  the  ischium,  and  is 
due  to  infection  from  an  abrasion,  fissure,  or  ulceration  of  the  rectum 
or  anus.  The  lymph  nodes  about  the  rectum  first  become  im'olved, 
and  thence  the  invading  organisms  effect  entrance  into  the  fossa. 
Occasionally  the  abscess  is  tuberculous  as  a  result  of  tuberculosis 
of  the  bony  pelvis. 

Symptoms. — Tenderness,  induration,  swelling,  and  redness  are 
found  on  the  affected  side;  but  no  fluctuation  can  be  detected  until 
late  in  the  course  of  the  disease,  owing  to  the  depth  of  the  abscess 
and  the  density  of  the  fascia.  Defecation  is  painful.  The  child  can- 
not bear  its  weight  on  the  affected  buttock  while  sitting  down.    The 


368         DISEASES  OF  THE  GASTRO-INTESTINAL   TRACT 

temperature  usually  runs  high,  and  other  constitutional  symptoms  of 
pus  formation  appear. 

Treatment. — ^The  abscess  should  be  freely  incised  and  the  cavity 
washed  out  with  hydrogen  peroxide,  after  which  free  drainage  should 
be  kept  up  until  the  discharge  of  pus  ceases.  If  the  case  is  one  of 
tubercular  infection,  the  abscess  should  be  opened  and  the  affected 
bone  curetted.  After  the  cavity  is  perfectly  clean  it  should  be  closed 
without  drainage. 

If  pus  formation  again  becomes  evident,  the  same  treatment  should 
be  repeated,  and  several  incisions  of  the  abscess  are  sometimes  required. 
It  is  well  to  give  these  children  a  purgative  dose  of  castor  oil.  If 
tuberculosis  be  evident  they  should  be  kept  out  of  doors,  put  on  a 
nourishing  diet,  and  sent  away  to  the  country,  mountains,  or  seashore 
if  practicable. 


DISEASES  OF  THE   LIVER. 

Organic  diseases  of  the  liver  are  extremely  rare  during  childhood; 
on  the  other  hand,  this  organ  frequentl}^  becomes  affected  during  the 
course  of  the  acute  infectious  diseases  so  common  among  children. 

SIZE    AND   LOCATION    OF   THE   LIVER. 

The  liver  is  relatively  much  larger  in  the  child  than  in  the  adult, 
its  weight  being  from  -jq-  to  2V  of  the  entire  weight  of  the  body.  At 
birth  it  weighs  about  four  ounces  (128  Gm.),  which  is  approximately 
4  per  cent,  of  the  body  weight;  but  its  subsequent  growth  is  not  in 
proportion  to  that  of  the  other  tissues  of  the  body,  therefore  in  the 
adult  its  weight  represents  only  ^^q-  of  that  of  the  entire  body.  When 
the  organ  is  outlined  upon  the  body  surface,  liver  dulness  is  found  to 
extend  from  the  fifth  interspace  in  the  mammary  line  to  about  an  inch 
below  the  border  of  the  ribs;  in  the  axillary  line  it  reaches  the  seventh 
intercostal  space ;  and  posteriorly  it  extends  to  the  ninth  intercostal  space. 

In  order  to  examine  the  liver  to  the  best  advantage,  the  child  should 
lie  upon  its  back  with  the  knees  flexed  to  relax  the  abdominal  muscles. 
The  lower  border  may  be  outlined  by  percussion,  and  by  light  pal- 
pation from  below  upward  using  only  the  finger  tips.  The  upper 
border  is  easily  outlined  by  percussion,  since  there  is  a  marked  contrast 
between  liver  dulness  and  pulmonary  resonance. 

In  rare  instances  the  liver  occupies  an  abnormal  position.  It  may 
be  found  on  the  left  side  of  the  body  in  cases  of  transposition  of  the 
viscera;  it  may  be  forced  downward  by  right-sided  pleural  effusion, 
or  by  contraction  of  the  chest  wall  from  rickets;  or  its  weight  may 
stretch  and  elongate  the  ligaments  which  hold  it  in  place,  and  make 
it  sink  to  a  lower  level  in  the  abdomen  than  is  normal.  This  accident 
occm^s  most  commonly  in  infants  and  young  children  who  are  ill- 
nourished  and  anemic. 


JAUNDICE,   OR  ICTERUS  369 

BILE. 

The  composition  of  bile,  which  is  the  product  of  the  secretory 
activity  of  the  hver  cells,  differs  slightly  in  the  child  from  that  in  the 
adult.  It  contains  a  larger  quantity  of  mucin  and  less  of  acids.  The 
relatively  small  proportion  of  acids  is  largely  responsible  for  the 
difficulty  with  which  an  infant  digests  fats,  and  accounts  in  some 
degree  for  the  ease  with  wdiich  fermentation  is  set  up  in  the  intestinal 
canal.  The  other  constituents  of  bile  are  fat,  organic  salts,  lecithin, 
cholesterin,  and  about  97  per  cent,  of  w^ater. 

JAUNDICE,    OR   ICTERUS. 

Icterus  neonatorum,  which  is  usually  a  physiological  phenomenon,  is 
the  most  common  form  of  jaundice  in  infancy.  After  the  third  or 
fourth  year  acute  catarrhal  jaundice,  which  is  quite  rare  during 
infancy,  is  as  common  in  children  as  in  adults;  but  other  forms  of 
jaundice  are  seldom  observed. 

Obstructive  Jaundice. — Etiology. — Jaundice  is  merely  a  symptom 
of  disease.  It  is  a  staining  of  the  skin  and  secretions  with  pigment 
derived  either  from  the  bile  or  from  the  blood.  In  the  latter  case  the 
jaundice  is  called  hematogenous,  because  of  its  origin;  and  when  the 
pigment  is  derived  from  the  bile  as  a  result  of  obstruction  to  the  flow 
of  bile  through  the  bile  ducts  it  is  called  hepatogenous.  Obstructive 
jaundice  is  another  term  for  the  hepatogenous  variety,  while  the 
hematogenous  is  sometimes  called  unobstructive  jaundice. 

Obstructive  jaundice  is  by  far  the  rnore  common,  and  may  be  due 
either  to  congenital  obliteration  or  stenosis  of  the  bile  ducts,  to 
impaction  of  a  gall-stone  in  the  common  duct,  to  pressure  upon  the 
lumen  of  the  bile  ducts  by  enlarged  glands  or  tumors  in  adjacent 
organs  and  tissues,  or  to  fecal  accumulations  within  the  intestines. 
Xevy  rarely  the  bile  ducts  may  be  obstructed  by  an  impacted  round- 
worm or  by  hydatid  or  echinococcic  cysts. 

The  most  common  form  of  obstructive  jaundice  is  the  acute  catarrhal 
type  which  arises  when  the  mucous  membrane  of  the  bile  ducts  becomes 
swollen,  and  obliterates  the  lumen  of  the  bile  passages.  This  inflam- 
mation of  the  bile  passages  is,  as  a  rule,  the  result  of  extension  of 
inflammation  from  the  small  intestine;  but,  although  it  is  usually 
associated  with  gastro-intestinal  disturbance,  it  is,  now  generally 
believed  to  be  of  infectious  origin,  a  belief  which  is  supported  by  the 
occurrence  of  several  epidemics  of  acute  catarrhal  jaundice.  It  is 
sometimes  a  complication  in  the  acute  infections,  especially  scarlet 
fever  and  measles.  So  far  bacteriological  investigations  have  failed 
to  demonstrate  the  presence  of  any  specific  organism  in  acute  catarrhal 
jaundice,  although  Jaeger  isolated  a  bacillus  of  the  proteus  group 
(proteus  fluorescens)  in  the  urine  of  these  patients. 

Symptoms. — The  most  characteristic  sign  of  jaundice  of  the  obstruc- 
tive type  is  the  yellowish  discoloration  of  the  skin  caused  by  the 
24 


370  DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 

deposition  of  bile  pigments.  The  skin  is  also  irritated  by  these  pig- 
ments; it  itches  intensely,  and  may  even  present  lesions  of  urticaria 
lichen,  or  fm-imculosis.  In  addition  to  the  discoloration  of  the  skin, 
the  sclera  has  a  yellowish  tinge,  and  the  urine  and  perspiration  may 
also  be  stained.  The  stools,  on  the  other  hand,  are  clay-colored,  and 
absolutely  devoid  of  biliary  coloring  matter,  while  the  tears,  saliva, 
and  mucus  are  also  free  from  discoloration. 

In  order  to  test  the  urine  for  the  presence  of  bile,  put  a  few  drops 
of  urine  and  half  as  many  drops  of  nitric  acid  on  a  porcelain  plate, 
and  allow  them  gradually  to  approach  each  other  and  fuse.  If  bile 
pigment  be  present  a  play  of  colors  appears  in  which  red,  violet,  green, 
and  yellow  predominate. 

A  slow  pulse  is  very  characteristic  of  jaundice  in  the  adult,  but  is, 
as  a  rule,  not  so  invariable  in  children;  it  is  due  to  the  sedative  action 
of  the  bile  salts  upon  the  heart  mechanism.  The  principal  subjective 
symptoms  of  the  ordinary  case  of  jaundice  are  vertigo,  headache, 
nervous  irritability,  and  depression  of  spirits  which  in  the  child  is 
apt  to  manifest  itself  as  stupidity. 

In  acute  catarrhal  jaundice  the  foregoing  symptoms  are  usually 
preceded  by  more  or  less  gastro-intestinal  disturbance  with  nausea, 
vomiting,  anorexia,  diarrhea  or  constipation,  and  pain  and  tenderness 
in  the  epigastrium.  The  liver  is  generally  somewhat  enlarged,  and 
may  be  quite  tender.  There  is  a  rise  in  temperature  to  101°  or  102' 
F.;  but,  aside  from  a  mild  feeling  of  malaise,  the  child  does  not  espe- 
cially complain,  and  many  of  these  cases  are  treated  in  the  out-patient 
dispensaries. 

Severe  obstructive  jaundice  is  rare,  but  may  occasionally  be  met 
with.  The  mvolvement  of  the  nervous  system  is  pronounced,  and  is 
marked  by  delirium,  con\aJsions,  and  unconsciousness.  There  is 
also  high  fever,  and  rapid,  irregular  pulse  and  respirations.  In  these 
cases  death  usually  supervenes  Cj[uickly  from  exhaustion.  Important 
features  in  jaundice  are  the  tendency  to  hemorrhage  and  the  lengthened 
coagulation  time  of  the  blood,  which  contramdicate  any  but  the 
most  urgent  operations  on  these  children. 

Diagnosis. — ^The  diagnosis  of  jaundice  is  easy;  but  the  real  purpose 
in  diagnosis  is  to  discover  the  cause  and  the  seat  of  the  obstruction. 
The  acute  catarrhal  type  may  be  diagnosed  by  its  mild  s\Tiiptoms 
together  with  a  history  of  associated  gastro-intestinal  derangement 
and  by  excluding,  as  far  as  possible,  other  causes  of  obstruction  of 
the  bile  ducts. 

Prognosis. — In  acute  catarrhal  jaundice,  unless  associated  with  an 
acute  infectious  disease,  the  prognosis  is  favorable.  In  jaundice  due 
to  other  causes,  the  prognosis  depends  absolutely  upon  the  gravity 
of  the  causative  factor.  The  course  and  duration  of  an  attack  of 
jaundice  also  depend  largely  upon  the  cause.  Ordinary  simple  catar- 
rhal jaundice  runs  a  coiu-se  of  two  to  six  weeks'  duration,  but  in 
exceptional  cases  may  last  much  longer. 


JAUNDICE,   OR  ICTERUS  371 

Treatment. — Unless  there  is  elevation  of  temperature,  the  child 
need  not  remain  in  bed  but  should  be  kept  quiet.  An  initial  course  of 
calomel  should  be  given,  1  grain  in  doses  of  y  q-  of  a  grain  every  hour 
to  a  child  under  five  years  of  age,  and  2  grains  in  doses  of  |  of  a  grain 
to  the  child  above  five. 

The  diet  must  be  carefully  regulated,  and  starches,  sugars,  and  fatty 
foods  restricted.  Bland  and  easily  digestible  articles  of  food,  such  as 
broth,  skimmed  milk,  albumen-water,  and  toast  are  permissible  at 
the  onset  and,  as  improvement  is  noted,  lean  meat,  fish,  chicken,  and 
vegetables  may  be  allowed. 

The  bowels  must  be  kept  regular,  and  for  this  purpose  sodium  phos- 
phate, 10  to  20  grains,  calomel,  ^  to  ^  of  a  grain,  or  salme  mineral 
waters,  such  as  Carlsbad  or  Vichy,  may  be  given  daily. 

Alkaline  baths  are  beneficial,  and  may  easily  be  prepared  simply 
by  adding  2  ounces  each  of  sodium  bicarbonate  and  sodium  chloride 
to  a  tub  of  water.  When  the  itching  is  distressing,  a  wash  containing 
1  drop  of  phenol  to  the  ounce  may  be  applied  to  the  skin,  and  will 
usually  relieve  it.  Fresh  air  is  particularly  needful  in  these  cases,  and 
the  child  who  is  able  to  play  about  should  be  kept  out  of  doors  as  much 
as  possible. 

In  severe  attacks  of  jaundice  the  patient  should  be  put  to  bed  and 
a  hot-water  bag  or  mustard  plaster  applied  to  the  epigastrium  to 
relieve  the  pain.  If  this  does  not  bring  relief  paregoric  may  be 
administered  in  5-  to  10-drop  doses  every  three  hours.  To  control 
the  vomiting,  it  may  occasionally  be^necessary  to  give  cocaine,  -^q  to 
■jV  of  a  grain,  every  three  hours  until  the  vomiting  ceases.  In  the 
grave  types  of  jaundice  the  child's  strength  must  be  kept  up  by 
stimulation,  and  brandy,  10  to  20  drops,  and  aromatic  spirits  of 
ammonia,  5  to  10  drops,  may  be  given  every  two  or  three  hours  by 
mouth,  as  well  as  camphorated  oil,  1  to  3  drops,  and  strychnine 
sulphate,  4^0^  to  2~oir  of  a  grain,  hypodermically.  If  there  are  severe 
hemorrhages,  salt  solution  by  slow  proctoclysis,  and  lead  acetate,  yg- 
to  J  of  a  grain,  or  ergot,  1  to  2  grains,  should  also  be  given  every 
three  hours. 

Hematogenic  Jaundice. — Hematogenic,  or  non-obstructive,  jaundice, 
which  is  due  to  alteration  in  the  state  of  the  blood,  may  be  observed 
during  the  course  of  a  great  number  of  diseases  among  which  are  the 
following :  sepsis,  typhoid  fever,  malaria,  congestion  of  the  liver  from 
cardiac  or  pulmonary  disease,  syphilis,  tuberculosis,  specific  fevers, 
acute  yellow  atrophy  of  the  liver,  Winckel's  disease,  Weil's  disease, 
also  after  severe  hemorrhage,  in  phosphorus  and  phenol  poisonmg, 
and  in  cyclic  vomiting. 

Symptoms. — The  symptoms  of  hematogenous  jaundice  are  chiefly 
those  of  the  underlying  causative  factor.  The  jaundice  is  less  intense 
than  in  the  obstructive  type,  and  the  urine  is  less  bile-stained,  although 
the  amount  of  true  urinary  pigments,  especially  urobilin,  may  be  very 
much  increased.  In  this  type  of  jaundice  the  stools  are  not  clay- 
colored. 


372  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

Course  and  Prognosis. — The  dm-ation  of  hematogenous  jaundice  is 
usually  brief,  since  many  of  the  conditions  which  cause  it  are  fatal. 

Treatment. — The  treatment  of  unobstructive  jaundice  is  essentially 
that  of  the  underlying  condition. 

CONGESTION    OF    THE   LIVER. 

There  are  two  forms  of  congestion  of  the  liver — active  and  passive. 
Active  congestion,  which  is  iriuch  less  grave  than  the  passive  type, 
occurs  physiologically  after  each  meal,  but  may  be  much  aggravated 
by  overfeeding.  This  form  of  congestion  may  also  be  associated  with 
acute  gastro-intestinal  disturbances  and  infectious  diseases.  Rarely 
are  any  symptoms  referable  to  the  liver  except  an  occasional  dull 
ache,  or  a  feeling  of  fuhiess  in  the  hepatic  region. 

Chronic,  or  passive,  congestion  of  the  liver  is  much  more  common 
during  childhood  than  the  acute  form,  and  is  always  due  to  some 
obstruction  to  the  flow  of  blood  toward  or  through  the  heart.  Val- 
vular heart  disease  is  the  most  common  cause  of  passive  congestion; 
but  it  may  also  be  due  to  pulmonary  disease,  such  as  fibroid  pneumonia, 
chronic  tuberculosis,  or  fibrosis  and  adhesions  of  the  pleura. 

Pathology. — If  chronic  congestion  of  the  liver  persists  for  a  long 
period,  organic  changes  take  place.  The  liver  becomes  reduced  in 
size,  and  on  section  it  has  a  nutmeg  appearance,  due  to  an  alternation 
of  dark  and  light  tints  produced  by  the  unequal  distribution  of  the 
blood  within  the  liver.    Its  external  surface  is  smooth. 

Symptoms. — In  chronic  congestion  the  symptoms  are,  as  a  rule, 
mild.  There  may  be  slight  tenderness  m  the  hepatic  region  wdth,  in 
some  cases,  gastro-intestinal  disturbance,  such  as  nausea,  anorexia, 
and  constipation.  The  liver  is  at  first  enlarged  and  tender;  at  times 
it  may  be  possible  to  detect  pulsation  of  the  organ.  Jaundice  is  rare; 
ascites  occurs  late  in  the  course  of  the  disease;  the  urme  is  scanty, 
and  of  high  specific  gravity.    In  most  cases  the  spleen  also  is  enlarged. 

Prognosis. — In  passive  congestion  of  the  liver  the  prognosis  depends 
entirely  upon  the  causative  factor  and  is,  as  a  rule,  less  favorable  than 
when  the  congestion  is  active. 

Treatment. — The  most  important  point  in  the  treatment  of  passive 
congestion  of  the  liver  is  the  relief  of  the  primary  disease.  Purgation 
and  depletion  are  beneficial  in  both  the  active  and  passive  forms, 
and  may  be  eftected  by  the  admmistration  of  1  to  3  grains  of  calomel, 
followed  by  1  dram  of  sodium  phosphate,  or  2  to  4  drams  of  magnesium 
sulphate.  The  diet  should  be  greatly  restricted,  and  until  improve- 
ment takes  place  only  liquids  allowed. 

The  following  prescription  for  a  child  of  five  years  has  been  found 
valuable  in  the  after-treatment  of  these  cases: 

I^ — Tinct.  nucis  vomici f3J 

Acidi  nitrici  diluti f3J 

Aqua q.  s.  ad.  fgiij 

Sig. — Teaspoonful  in  water  three  times  a  day. 


CONGENITAL  ACHOLURIC  JAUNDICE  373 

ENLARGEMENT    OF    THE   LIVER. 

An  enlarged  liver  is  quite  a  common  finding  in  children,  and  is  met 
with  much  more  frequently  than  in  adult  life.  Simple  enlargement 
is  observed  in  congestion  due  to  pulmonary  or  cardiac  disease,  and 
occasionally  accompanies  the  acute  infections.  The  most  common 
forms  of  enlargement  are  those  due  to  syphilis  and  rachitis.  There 
is  also  a  certain  degree  of  enlargement  of  the  liver  in  all  diseases  of 
the  blood,  especially  in  the  pseudoleukemia  of  von  Jaksch;  but  in 
these  cases  enlargement  of  the  spleen  is  more  marked. 

Other  maladies  which  cause  increase  in  the  size  of  the  liver  are 
hypertrophic  cirrhosis,  fatty  infiltration,  hepatic  and  subphrenic 
abscess,  amyloid  and  hydatid  disease,  and  Still's  disease.  The  asso- 
ciation of  enlarged  spleen  with  enlargement  of  the  liver,  and  vice  versa,  is 
quite  common  in  children,  and  in  the  majority  of  the  forms  of  enlarged 
liver  mentioned  above  the  spleen  also  is  increased  in  size. 

There  are  a  number  of  intra-abdominal  and  thoracic  conditions 
which  at  first  may  lead  the  physician  to  think  the  liver  enlarged,  but 
these  can  be  differentiated  from  hepatic  enlargement  by  careful 
examination.  The  liver  may  be  displaced  downward  by  a  right-sided 
empyema,  pleural  effusion,  or  a  circumscribed  peritoneal  effusion 
between  the  liver  and  diaphragm;  but  in  these  conditions  there  is 
flatness  over  and  above  the  upper  part  of  the  normal  area  of  liver 
dulness.  Tumors  of  the  right  kidney  or  other  organs  adjacent  to  the 
liver  may  by  their  proximity  either  displace  the  liver  or  cause  an 
apparent  increase  in  liver  dulness;  but  upon  careful  examination  a 
line  of  demarcation  between  the  tumor  and  the  liver  can  usually  be 
made  out. 

CONGENITAL    ACHOLURIC   JAUNDICE. 

This  disease,  which  is  also  known  as  familial  jaundice  and  congenital 
family  jaundice,  is  hereditary,  occurring  usually  in  several  members 
of  a  family,  and  is  due  to  an  abnormal  state  of  the  blood  which  is 
believed  to  be  inherited. 

Two  forms  of  familial  jaundice  are  recognized:  one  type  in  w^hich 
the  jaundice  appears  at  birth  or  shortly  afterward,  and  another  in 
which  the  affection  does  not  manifest  itself  until  late  childhood  or 
early  adult  life.  A  peculiar  feature  of  the  malady  is  the  absence  of 
bile  in  the  urine,  hence  its  name  acholuric  jaundice.  Enlargement 
of  the  spleen  and  anemia  are  also  characteristic  features  of  familial 
jaundice. 

Etiology. — Heredity  is  the  most  important  etiological  factor,  and 
one  can  usually  obtain  a  history  of  the  disease  having  been  trans- 
mitted through  successive  generations  of  the  family.  Several  mem- 
bers of  a  family  may  suffer  from  it  at  the  same  time,  males  and 
females  being  affected  equally.  The  primary  cause  is  obscure,  but  it 
is  supposed  to  be  a  congenital  defect  in  the  hemopoietic  system  which 
produces  an  abnormal  state  of  the  blood. 


374  DISEASES  OF   THE  GASTRO-INTESTINAL  TRACT 

Pathology. — Familial  jaundice  is  hematogenic  in  origin,  and  is 
believed  to  be  due  to  a  congenital  abnormality  of  tbe  red  corpuscles 
which  renders  them  more  fragile  than  they  normally  are.  This  leads 
to  an  excessive  degree  of  hemolysis,  and  consequent  enlargement  of 
the  spleen  owing  to  increased  functional  activity,  also  to  the  production 
of  an  excessive  amount  of  bile  pigment  by  the  liver. 

Symptoms. — In  the  majority  of  cases  the  jaundice  is  present  at 
bii'th,  but  the  discoloration  of  the  skin  is  usually  slight,  and  the  other 
symptoms  are  mild.  In  some  cases  the  sclera  alone  shows  pigmen- 
tation, but  the  degree  of  discoloration  may  vary  greatly  from  time  to 
time  in  the  same  patient.  In  mild  cases  the  jaundice  tends  to  fade 
and  disappears  within  a  few  weeks. 

As  a  rule,  there  are  no  marked  symptoms  of  illness,  although  the 
child  may  occasionally  have  a  slight  fever  with  malaise  and  so-called 
biliousness.  The  liver  may  be  slightly  increased  in  size,  and  the 
spleen  is  always  decidedly  enlarged.  Although  the  urine  in  these 
cases  shows  no  bile  pigment,  yet  the  stools  are  bile-stained,  and  upon 
examination  of  the  urine  an  excess  of  urobilin  may  be  found. 

Changes  in  the  blood  vary  from  anemia  so  severe  that  it  causes 
death  to  merely  a  slight  alteration  in  the  blood  picture.  As  a  rule,  the 
blood  changes  are  most  marked  in  infancy,  and  when  the  blood  is 
microscopically  examined  a  great  reduction  in  the  number  of  red 
cells  is  noted;  many  of  them  are  smaller  than  normal,  and  usually 
a  few  nucleated  red  cells  are  present.  There  is  a  great  reduction  in 
hemoglobin  and  a  low  color  index;  but  the  leukocytes  are  practically 
unchanged. 

These  children  may  continue  to  have  such  attacks  all  through  life, 
but  they  are  less  severe  after  they  are  grown  up,  and,  as  a  rule,  do  not 
affect  the  general  health. 

Diagnosis. — In  familial  jaundice  the  diagnosis  can  be  made,  as  a 
rule,  on  the  history  of  the  disease  appearing  in  more  than  one  member 
of  a  family,  and  in  successive  generations.  Absence  of  bile  in  the 
urine,  and  alteration  of  the  blood  picture,  with  very  mild  subjecti\'e 
symptoms,  are  also  characteristic  findings  which  confirm  the  diagnosis. 

Prognosis. — This  is  least  favorable  in  very  young  infants  in  whom 
the  disease  is  associated  with  anemia.  Older  children  and  adults  suffer 
but  little;  and,  although  the  affection  is  liable  to  persist  throughout 
life,  the  attacks  occur  after  longer  intervals  with  increasing  age. 

Treatment. — There  is  no  known  cure  for  this  disease,  but  prophylaxis 
may  accomplish  much  in  preventing  attacks  of  jaundice  in  the  children 
who  have  inherited  it.  The  diet  should  be  carefully  regulated  so  as 
to  prevent  gastro-intestinal  disturbance,  and  the  surface  of  the  body 
should  be  kept  warm  and  never  allowed  to  become  chilled.  Fowler's 
solution  in  1-  to  3-drop  doses,  or  tincture  of  ferric  chloride,  2  to  10 
drops,  should  be  administered  for  the  anemic  condition  of  the  blood. 
Any  measures  which  help  to  build  up  the  general  health,  such  as 
moderate  outdoor  exercise,  ample  rest^  and  change  of  surroundings, 
are  beneficial  in  these  cases. 


CONGENITAL  OBLITERATION  O'F  THE  BILE  DUCTS       375 

CONGENITAL    OBLITERATION    OF    THE   BILE  DUCTS. 

This  affection  is  quite  rare,  but  a  number  of  cases'  are  recorded 
in  medical  literature.  In  some  instances  it  has  been  observed  in 
more  than  one  member  of  a  family. 

Etiology. — ^The  disease  occurs  more  frequently  in  male  than  in 
female  children,  and  is  to  a  certain  extent  hereditary.  The  exact 
cause  is  unknown;  but  it  is  thought  to  be  due  to  maldevelopment, 
since  it  is  occasionally  accompanied  by  other  congenital  anomalies. 
It  may  also  be  the  result  of  an  idiopathic  inflammation  of  the 
bile  ducts  in  early  life,  or  possibly  may  be  due  to  congenital 
syphilis. 

Pathology. — In  these  cases  the  liver  shows  marked  cirrhotic  change, 
being  hard,  and  olive  green  in  color  from  staining  by  the  obstructed 
bile.  The  gall-bladder  may  be  completely  obliterated,  or  represented 
merely  by  a  small  fibrous  sac  with  scarcely  any  lumen.  In  some 
cases  it  contains  a  little  clear  mucus;  exceptionally,  when  the  common 
duct  alone  is  obstructed,  it  may  be  distended.  The  common  bile  duct 
and  the  hepatic  ducts  are  often  entirely  obliterated,  nothing  remaining 
but  fibrous  cords  which  when  opened  may  or  may  not  disclose  a 
narrow  lumen.  The  bile  capillaries  are  dilated  and  distended  with 
bile,  which  is  usually  thick  and  inspissated. 

Microscopic  examination  of  a  section  of  liver  tissue  shows  but 
little  change  in  the  liver  substance  and  practically  no  degeneration  of 
the  liver  cells;  but  the  bile  capillaries  are  irregularly  distended  and 
choked  up  with  biliary  secretion.  The  spleen  is  also  enlarged,  and 
together  with  the  pancreas  may  show  extensive  fibrosis. 

Symptoms. — Infants  suffering  from  this  condition  may  appear 
normal  at  birth,  but  if  jaundice  is  not  present  then  it  usually  develops 
in  the  course  of  two  or  three  days,  and  rapidly  becomes  intense.  In 
exceptional  cases  jaundice  may  not  appear  for  two  or  three  weeks, 
even  though  the  bile  ducts  were  obliterated  at  birth.  The  intensity 
of  the  jaundice  varies;  but  the  pigmentation  never  leaves  the  skin, 
and  in  addition  there  may  be  subcutaneous  hemorrhages  and  extrava- 
sations of  blood  into  the  mucous  membranes.  The  stools  are  white 
because  of  the  absence  of  bile,  and  may  be  quite  dry  and  hard.  The 
urine  is  bile-colored,  and  stains  the  napkin,  but  the  amount  of  biliary 
coloring  matter  varies  considerably. 

On  examination,  the  abdomen  is  often  found  to  be  distended,  and 
may  contain  an  abnormal  amount  of  peritoneal  fluid,  although  the 
distention  is  partly  due  to  enlargement  of  the  liver  and  spleen,  which 
may  be  quite  marked.  In  a  number  of  cases  the  general  health  is 
seemingly  unaffected;  but  in  the  course  of  a  few  weeks  or  months  the 
body  nutrition  begins  to  fail,  exhaustion  and  emaciation  are  progres- 
sively worse,  and  death  usually  occurs  within  a  year.  The  majority, 
however,  succumb  in  much  less  than  a  year,  and  death  may  ensue 
shortly  after  birth  from  hemorrhages  about  the  navel,  under  the  skin, 
or  from  the  stomach  gr  intestines. 


376  DISEASES  OF   THE  GASTRO-IXTESTIXAL   TRACT 

Diagnosis. — To  the  general  practitioner  the  diagnosis  is  difficult; 
and,  unless  something  strongly  suggests  the  condition  it  may  notbe 
recognized.  ^Yhen  the  disease  is  suspected  the  following  symptoms 
will  point  to  the  diagnosis:  intense  jaundice  of  obstructive  type, 
coming  on  within  a  few  days  after  birth,  and  associated  with  hemor- 
rhages into  the  skin  and  from  the  mucous  membranes. 

Prognosis. — The  outlook  is  most  unfavorable,  since  the  disease  can- 
not possibly  be  influenced  by  medicine  or  surgery  except  in  syphilitic 
cases,  and  here  slight  impro^'ement  may  follow  antisyphilitic  treat- 
ment. 

Treatment. — It  is  perfectly  obvious  that  no  treatment  will  avail 
when  the  bile  ducts  are  obliterated,  and  even  surgical  intervention 
can  be  of  use  only  in  those  cases  where  there  is  merely  obstruction  to 
the  flow  of  bile.  Since  a  few  of  these  cases  appear  to  be  of  syphilitic 
origin,  mercury  may  be  administered  orally  in  the  form  of  calomel, 
I  to  J  of  a  grain,  or  in  gray  powder,  1  to  3  grains  daily;  or  it  may  be 
given  by  inunction,  |  to  1  dram  of  mercurial  ointment  being  rubbed 
into  the  skin  every  day.  Potassium  iodide  in  1-  to  .5-grain  doses  three 
times  daily  may  also  be  given  for  its  antisyphilitic  properties,  and 
because  it  is  theoretically  supposed  to  dissolve  fibrous  tissue,  and  thus 
widen  the  lumen  of  the  stenosed  ducts. 

Aside  from  this  mode  of  treatment,  nothing  can  be  done  but  to 
keep  up  the  general  health  of  the  child  by  judicious  feeding  and  other 
hygienic  measures. 

STENOSIS    OF    THE   BILE    DUCTS. 

Stenosis  of  the  biliary  ducts  may  also  occur  in  children  from 
imflammatory  changes  withm  the  lumen  of  the  ducts,  such  as  might 
be  caused  by  the  passage  of  a  large  gall-stone.  Pressure  from  without 
may  also  occlude  the  biliary  tracts.  Occasionally  stenosis  is  produced 
by  neoplasms  of  adjacent  tissues,  by  perihepatitis,  and  by  syphilis. 
Most  of  the  symptoms  are  due  to  the  underlying  cause  of  the  stenosis, 
and  an  accurate  diagnosis  of  the  affection  is  rarely  made. 

Treatment. — The  treatment  depends  entirely  upon  the  cause,  and 
consists  in  the  removal  of  the  stenosis  and  the  establishment  of  free 
drainage  of  the  bile. 

ACUTE    YELLOW   ATROPHY    OF    THE   LIVER. 

This  very  rare  disease  is,  fortunately,  especially  uncommon  in 
children.  It  is  characterized  by  fatty  degeneration  and  atrophy  of 
the  liver  accompanied  by  toxic  symptoms,  and  is  almost  invariably 
fatal. 

Etiology. — Acute  yellow  atrophy  sometimes  accompanies  the  acute 
infections,  notably  diphtheria,  erysipelas,  and  typhoid  fever;  occa- 
sionally it  follows  chloroform  poisoning.  It  has  also  been  seen  in 
association  with  syphilis,  but  its  true  cause  is  as  yet  undiscovered. 


ACUTE   YELLOW  ATROPHY  OF   THE  LIVER  377 

Bo\'s  are  more  liable  to  contract  the  disease  than  girls;  bnt  in  adult 
life  more  women  suflfer  from  it  than  men,  owing-  to  the  predisposing 
influence  of  pregnancy. 

Pathology. — Postmortem  examination  reveals  a  liver  about  one-half 
the  normal  size,  reddish  in  color,  its  surface  presenting  a  mottled 
appearance,  with  areas  of  red,  green,  gray,  and  yellow.  In  consequence 
of  the  great  destruction  of  liver  cells  the  organ  rapidly  dwindles  i  ^ 
size,  sometimes  even  in  four  or  five  days.  The  capsule  is  wrinkled 
and  loose,  the  tissue  is  soft  and  flabby,  the  lobular  markings  may  be 
wholly  obliterated.  On  section  the  surface  is  either  of  a  uniform  yellow 
color  or  presents  alternate  areas  of  red  and  yellow.  The  yellow  areas 
represent  an  earlier  stage  of  the  disease;  they  contain  degenerated 
liver  cells  within  which  are  fat  droplets  of  all  sizes.  The  red  areas 
are  composed  of  cellular  debris  and  connective  tissue  in  the  meshes 
of  which  may  be  found  fat  drops  and  biliary  coloring  matter. 

Pseudo-bile  ducts,  or  canaliculi,  and  a  certain  degree  of  cell  infil- 
tration of  the  interstitial  tissue  may  be  observed  under  the  microscope, 
and  indicate  an  attempt  at  regeneration  of  the  liver  cells  and  begin- 
ning fibrosis.  The  bile  ducts  are  in  a  state  of  catarrhal  inflammation. 
Leucin  and  tyrosin  may  be  found  in  the  interior  of  the  hepatic  and 
portal  veins.  The  skin  and  other  viscera  are  usually  deeply  bile- 
stained.  There  may  be  small  hemorrhages  in  various  parts  of  the 
body.  The  spleen  is  enlarged;  there  are  fatty  changes  in  the  heart 
muscle  and  renal  epithelium,  and  an  abnormal  amount  of  serum  within 
the  serous  cavities. 

Symptoms. — This  disease  begins  insidiously,  and  for  several  days 
there  may  be  merely  slight  evidences  of  gastro-intestinal  derangement, 
such  as  anorexia,  nausea,  vomiting,  jaundice,  malaise,  headache,  and 
abdominal  distress.  The  liver  is  at  this  period  believed  to  be  enlarged; 
but  the  symptoms  are  so  mild  that  the  cases  rarely  come  under  obser- 
vation at  this  early  stage.  Following  these  symptoms,  the  disease 
suddenly  assumes  a  grave  aspect;  the  jaundice  deepens,  vomiting 
becomes  severe,  and  there  is  an  increase  in  abdominal  pain. 

Blood  may  be  found  in  the  vomitus  or  passed  in  the  stool.  Sub- 
cutaneous hemorrhages  throughout  the  body  may  follow  slight  injuries, 
and  there  may  be  bleeding  from  the  gums.  The  blood  picture  usually 
shows  a  moderate  leukocytosis  (15,000  to  20,000).  Cerebral  symptoms, 
such  as  delirium,  convulsions,  and  drowsiness  or  coma,  are  not  uncom- 
mon. The  urine  decreases  in  quantity,  is  deeply  bile-stained,  of  high 
specific  gravity,  and  contains  leucin  and  t^Tosin.  The  temperature 
is  generally  a  little  above  normal,  but  may  be  subnormal,  although 
there  is  always  a  sharp  rise  before  death.  The  decrease  in  the  size  of 
the  liver  is  remarkable;  in  some  cases,  a  few  days  after  the  onset  of 
the  disease,  it  can  no  longer  be  outlined  either  by  percussion  or 
palpation. 

Diagnosis. — At  the  onset  of  the  disease  an  accurate  diagnosis  is 
impossible,  since  there  are  no  characteristic  symptoms;  but,  when 
fully  developed,  a  case  of  acute  yellow  atrophy  of  the  liver  should 


378  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

not  be  difficult  to  recognize  except  because  of  its  rarity.  The  cardinal 
features  upon  which  the  diagnosis  should  be  based  are  the  intense 
jaundice  with  ecchymoses,  slight  fever,  persistent  vomiting,  and 
symptoms  of  cerebral  irritation.  The  diagnosis  may  sometimes  be 
confirmed  by  physical  examination,  which  reveals  a  great  reduction 
in  the  size  of  the  liver  and  enlargement  of  the  spleen. 

Prognosis. — The  disease  usually  ends  fatally  within  a  short  time, 
and  the  mortality  is  so  great  that  reported  recoveries  may  probably 
be  attributed  to  error  in  diagnosis.  The  usual  duration  of  the  disease 
is  from  two  to  three  weeks. 

Treatment. — The  treatment  of  acute  yellow  atrophy  of  the  liver  is 
almost  purely  symptomatic,  for  little  can  be  done  to  arrest  the  progress 
of  the  disease.  At  the  onset  a  course  of  1  or  2  grams  of  calomel  in 
divided  doses  should  be  given,  followed  by  |  to  2  drams  of  magnesium 
sulphate.  Rest  in  bed  is,  of  course,  imperative.  The  diet,  while  light, 
should  contain  the  maximum  of  nourishment  in  order  to  support  the 
child's  vitality.  In  the  cases  with  cerebral  s\Tnptoms  an  ice-bag  may 
be  applied  to  the  head,  and  headache  relieved  by  the  admmistration 
of  phenacetin  or  antipjTin,  2  to  3  grams.  Salme  solution,  given  by 
slow  proctoclysis,  may  possibly  diminish  toxemia  and  keep  up  the 
child's  strength. 

CHOLELITHIASIS. 

Gall-stones  are  extremely  rare  in  children,  but  may  occur  at  any 
age  from  infancy  to  puberty.  In  the  newborn  they  are  usually  fatal, 
and  even  ui  older  infants  cause  death  within  a  few  weeks.  Jaundice 
is  intense;  m  mfancy  it  may  be  the  only  perceptible  s^Tiiptom;  but 
in  older  children  gall-stones  give  rise  to  the  same  s^Tiiptoms  as  are 
observed  in  the  adult. 

Diagnosis. — In  older  children  the  diagnosis  can  usually  be  made 
from  the  symptoms;  but  in  infants  few  cases  are  recognized. 

Treatment. — The  treatment  is  almost  wholly  surgical,  and  consists 
in  the  operative  removal  of  the  stones,  which  are  generally  found  in 
the  common  duct. 

ABSCESS   OF   THE  LIVER. 

This  affection  is  extremely  rare  during  childhood.  As  m  the  adult, 
abscess  of  the  liver  may  be  either  single  or  multiple,  but  is  alwaj^s  of 
microbic  origin. 

Etiology. — ]\Iost  abscesses  in  this  organ  arise  from  infection  in  the 
portal  area  or  from  suppurative  processes  elsewhere  in  the  abdomen, 
such  as  appendicitis  or  suppuration  of  the  mesenteric  glands.  Abscess 
formation  in  the  liver  may  also  be  due  to  sepsis,  pyemia,  peritonitis, 
typhoid  fever,  traumatism,  phlebitis,  or  tuberculosis,  and  has  been 
known  to  follow  the  migration  of  round  worms  into  the  biliary 
passages.  Amebic  abscess  of  the  liver  is  rarely  seen  m  children,  even 
when  amebic  dysentery  is  prevalent. 


SUBPHRENIC  ABSCESS  379 

Pathology. — The  right  lobe  of  the  Uver  is  the  most  common  seat  of 
an  abscess,  although  in  some  cases  the  whole  lobe  may  form  an  abscess 
cavity.  The  liver  is  usually  enlarged;  but  there  may  be  no  visible 
change  in  its  contour  if  the  abscess  be  deep-seated.  The  content  of 
the  abscess  is  usually  pus  which  may  rupture  into  the  right  pleural 
cavity,  the  peritoneum,  or  the  pericardium,  and  cause  death;  in 
exceptional  cases  it  may  be  discharged  through  the  abdominal  wall  by 
means  of  a  fistulous  opening. 

Symptoms. — In  abscess  of  the  liver  these  are  usually  severe,  but  in 
rare  cases  they  may  be  latent.  As  a  rule,  there  is  pain  in  the  hepatic 
region,  and  the  liver  is  tender.  Chills  and  sweats  usually  accompany 
the  fever  which  is  the  most  constant  feature  of  the  disease,  and  ranges 
from  103°  to  105°  F.  Jaundice  is  not  invariably  present,  but  occurs 
in  about  50  per  cent,  of  the  cases,  although  it  is  never  intense.  Vomit- 
ing and  diarrhea  are  not  uncommon.  In  severe  cases  prostration  comes 
on  rapidly. 

On  physical  examination  the  liver  is  usually,  but  not  always,  found 
to  be  enlarged.  When  there  is  enlargement,  it  spreads  upward  in 
the  midaxillary  and  mammary  lines,  and  is  due  to  the  pus  present  and 
to  hyperemia  and  swelling  of  the  hepatic  cells.  Fluctuation  is  a  late 
symptom,  but  can  generally  be  demonstrated,  and  a  characteristic 
edematous  condition  of  the  skin  and  abdominal  wall  over  the  hepatic 
region  is  observed.  Pronounced  nervous  symptoms  and  nephritis  are 
not  uncommon  in  the  latter  stages  of  this  disease. 

Diagnosis. — Hepatic  abscess  is  extremely  difficult  to  diagnose,  espe- 
cially in  the  early  stages.  Pain  in  the  hepatic  region,  and  referred  to 
the  right  shoulder,  tenderness  over  the  liver,  and  an  intermittent  fever 
which  is  not  malarial,  are  significant  diagnostic  points;  but  it  may  be 
impossible  to  state  positively  that  there  is  an  abscess  unless  pus  is 
withdrawn  by  means  of  an  aspirating  needle. 

Prognosis. — The  prognosis  is  usually  unfavorable,  even  when  a  case 
is  treated  early.  Death  is  due  to  toxemia  and  exhaustion.  The  mor- 
tality in  children  averages  about  75  to  85  per  cent. 

Treatment. — The  treatment  of  hepatic  abscess  is  essentially  surgical, 
and  unless  the  child  is  too  weak  for  operation  incision  and  drainage 
should  be  advised.  Operative  interference  is  useless  when  there  are 
multiple  suppurating  foci  within  the  liver. 

The  child's  vitality  and  strength  should  be  supported  by  a  nourish- 
ing diet  and  the  administration  of  tonics,  such  as  tincture  of  ferric 
chloride,  2  to  5  drops,  or  quinine  sulphate  ^  to  1  grain,  three  times  a 
day.  Morphine  may  be  necessary  for  the  relief  of  pain,  and  can  be 
given  hypodermically  in  4^^  to  2V  of  a  grain  dose,  according  to  the  age 
of  the  child. 

SUBPHRENIC   ABSCESS. 

Subphrenic  abscesses  are  rare  in  children,  but  are  occasionally  found 
in  association  with  suppurative  conditions  in  the  region  of  the  liver. 
The  most  common  site  of  such  an  abscess  is  the  space  behind  the  right 


380  DISEASES  OF    THE  GASTRO-IXTESTIXAL   TRACT 

coronary  ligament  and  extending  around  its  right  border  to  the  sub- 
hepatic space.  Sometimes  the  pus  accumulates  either  to  the  right  or 
left  of  the  falciform  ligament,  or  in  the  lesser  peritoneal  cavity. 

Etiology. — In  most  cases  subphrenic  abscess  is  secondary  to  appen- 
dicitis; but  it  may  follow  the  perforation  of  a  gastric  or  duodenal 
ulcer,  traumatism,  cholelithiasis,  Pott's  disease,  permephric  abscess, 
empyema,  pneumonia,  abscess  of  the  liver,  spleen,  or  pancreas,  or 
diffuse  peritonitis. 

Symptoms. — The  symptoms  are  pain  in  the  right  lower  chest  and 
about  the  diaphragm  and  liver,  alternating  chills,  fever,  and  sweats, 
dyspnea,  and  cough.  Examination  of  the  blood  in  these  cases  reveals 
a  leukocytosis  of  15,000  to  25,000.  The  abscess  cavity  may  contain 
pus  and,  in  some  instances,  gas  which  causes  either  tympany  or  flat- 
ness on  percussion  over  this  area. 

Diagnosis. — In  subphrenic  abscess  the  diagnosis  is  based  upon  the 
history  of  some  disorder  which  might  possibly  cause  an  abscess  to 
form  in  the  subphrenic  region;  upon  the  presence  of  dulness,  pain, 
tenderness,  a  tumor,  and  rigidity  of  the  overlying  muscles;  upon 
thoracic  signs  and  symptoms,  e.  g.,  pleural  friction  or  effusion,  upward 
displacement  of  the  right  lung,  and  increased  dulness  over  the  liver; 
and  upon  additional  general  signs  and  symptoms  of  suppuration,  such 
as  fever,  chills,  sweats,  leukocytosis,  and  progressive  wasting. 

Prognosis. — In  children  the  prognosis  is  very  unfavorable,  and  with- 
out operation  practicalh'  all  of  these  patients  die.  Operation  is 
attended  with  such  great  shock  that  the  mortality-rate  where  there 
is  surgical  intervention  is  over  50  per  cent. 

Treatment. — The  treatment  is  essentially  surgical,  and  consists  in 
securing  free  dramage.  The  incision  is  usually  made  through  the 
lower  chest  wall — very  rarely  through  the  abdomen.  Should  this 
mode  of  treatment  be  successful,  perfect  recovery  may  be  expedited 
by  administering  tonics,  such  as  syrup  of  the  iodide  of  iron,  10  to  20 
drops,  or  the  elixir  of  iron,  quinine,  and  strychnine  phosphates,  5  to  10 
drops,  three  times  daily;  by  putting  the  child  on  a  full  nourishing 
diet;  and,  if  living  in  the  city,  by  sending  it  away  to  the  country  or 
seashore  for  pure  air  and  change  of  scene. 

FUNCTIONAL   DISORDERS    OF    THE   LIVER. 

Functional  disorders  of  the  liver  are  quite  common  in  children, 
and  are  usually  referred  to  as  "bilious  attacks."  The  exact  nature  of 
such  derangements  is  unknown;  but  they  are  usually  accompanied 
by  intestinal  indigestion,  and  seem  to  depend  upon  a  lack  or  an  impov- 
erished quality  of  the  biliary  secretion,  for  the  stools  are  grayish-white 
or  clay-colored,  and  very  hard  and  dry.  In  some  instances  a  predis- 
position to  these  attacks  seems  to  be  inlierited,  the  father  or  mother 
also  being  affected  in  the  same  manner. 

Symptoms. — Durmg  such  a  bilious  spell  symptoms  indicative  of 
intestinal  indigestion  appear,  such  as  coated  tongue,  offensive  breath, 


CIRRHOSIS  OF   THE  LIVER  381 

anorexia,  nausea,  flatulence,  and  constipation  or  diarrhea  with  foul- 
smelling  stools.  For  a  day  or  two  preceding  the  attack  the  child  is 
fretful  and  peevish,  and  if  old  enough  complains  of  not  feeling  well. 
The  characteristic  appearance  of  the  stools  is  caused  by  incomplete 
absorption  in  consequence  of  the  lack  of  bile  elements  in  the  intestinal 
tract.  The  temperature  is  usually  elevated  to  100°  or  101°  F.,  but 
rarely  reaches  103°  F.    The  urine  is  highly  colored  and  concentrated. 

These  children  are  usually  pale  and  sallow,  and  during  an  attack 
may  become  very  weak ;  but,  as  a  rule,  the  symptoms  subside  in  a  day 
or  two,  and  recovery  rapidly  ensues. 

Treatment. — Prophylaxis  is  important.  Children  who  are  subject 
to  bilious  attacks  should  have  their  diet  carefully  regulated  and  be 
prevented  from  overeating.  Actual  treatment  consists  in  stopping 
all  food  for  twelve  to  twenty-four  hours,  and  giving  water  freely. 
Cholagogues  are  very  useful,  either  calomel,  podophyllum,  or  dilute 
nitric  acid,  the  calomel  preferably  administered  in  yV  to  i  of  a  grain 
doses  every  hour  until  1  or  2  grains  have  been  taken,  followed  in  six 
to  eight  hours  by  magnesium  sulphate,  |  to  1  dram;  or,  sodium  phos- 
phate in  10-  to  20-grain  doses  may  be  given  each  morning  in  hot 
water.  The  dose  of  podophyllum  is  f  to  |  grain,  and  of  dilute  nitric 
acid  1  to  2  drops,  three  times  daily. 

When  the  symptoms  have  disappeared,  the  diet  may  be  increased, 
and  cereals,  broths,  junket,  and  custards  allowed  until  the  full  diet 
is  gradually  resumed.  The  bowels  should  be  regulated  by  an  occasional 
course  of  calomel  followed  by  a  saline  laxative.  Abdominal  massage, 
moderate  exercise,  and  an  outdoor  life  are  especially  beneficial  in  these 
cases. 

CIRRHOSIS    OF    THE   LIVER. 

Cirrhosis  of  the  liver  is  uncommon  during  childhood,  and  most 
rare  in  infancy,  the  cases  increasing  in  frequency  as  adult  life  is 
approached.  It  is  more  common  in  boys  than  in  girls.  It  is  caused 
by  an  overgrowth  of  connective  tissue  at  the  expense  of  the  func- 
tionating cellular  structure  of  the  organ.  As  a  rule,  the  liver  becomes 
much  firmer  and  smaller  than  normal;  but  it  may  be  considerably 
enlarged,  and  in  some  cases  there  is  no  apparent  alteration  in  size. 
Two  forms  are  recognizable  in  children — the  atrophic  in  which  the 
liver  dwindles  in  size,  and  hypertrophic  cirrhosis  which  results  in 
enlargement  of  the  organ. 

Etiology. — Syphilis  is  one  of  the  chief  causes  of  this  aft'ection,  and 
it  is  in  association  with  congenital  lues  that  most  infantile  cases  of 
cirrhosis  occur.  Alcohol,  the  most  common  cause  of  cirrhosis  in  later 
life,  plays  but  an  insignificant  role  during  childhood. 

A  cardiotubercular  type  of  cirrhosis  has  been  described  in  associa- 
tion with  polyserositis,  but  is  comparatively  unimportant.  The 
eruptive  fevers  may  also  be  mentioned  as  having  in  some  way  a  pos- 
sible influence  in  the  production  of  cirrhosis.  In  many  cases  the  cause 
of  the  disease  is  obscure. 


382  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

Pathology. — In  atrophic  cirrhosis  the  hver  is  small,  hard,  and  lobu- 
lated,  and  has  an  uneven  surface.  There  is  an  excess  of  connective 
tissue  in  the  organ,  this  being  found  around  the  liver  lobules,  about 
the  bile  ducts,  and  dipping  down  from  the  capsule  into  the  liver  sub- 
stance, causing  the  capsule  to  become  adherent.  In  h^-pertrophic 
cirrhosis  the  liver  is  usually  enlarged,  the  fibrous  tissue  not  showing 
the  tendency  to  contract  which  it  does  in  the  atrophic  form.  There 
is  practically  no  compression  of  the  portal  vein;  but  the  biliary 
channels  are  obstructed,  the  flow  of  bile  impeded,  and  this  produces 
jaundice.  In  the  majority  of  cases  of  cirrhosis  of  the  liver  the 
spleen  is  enlarged  and  usually  shows  a  certain  degree  of  fibrosis. 

Symptoms. — ^This  disease  may  remain  latent  for  a  considerable 
time,  but  symptoms  of  secondary  conditions  due  to  cirrhosis  usually 
appear  quite  early.  Among  these  are  gastro-intestinal  disturbances 
due  to  chronic  congestion  of  the  gastric  mucous  membrane,  such  as 
nausea,  anorexia,  irregularity  of  the  bowels,  and  abdominal  discomfort. 
Epistaxis,  vomiting  of  blood,  and  melena  also  appear  as  the  result  of 
congestion  of  the  mucous  membranes,  but  by  relieving  the  engorge- 
ment are  rather  beneficial  than  harmful. 

These  children  are  pale  and  sallow;  the  veins  of  the  upper  abdomen 
and  lower  thorax  are  distended  and  quite  prominent;  their  flesh  is 
flabby;  there  is  a  steady  loss  in  weight.  There  may  be  slight  fever 
in  the  early  stages  of  atrophic  cirrhosis,  but  jaundice  appears  less 
frequently  than  would  be  expected.  In  many  cases  abdominal  dropsy 
is  the  first  symptom  which  calls  attention  to  the  cirrhotic  liver,  the 
accumulation  of  fluid  being  enormous,  and  causing  marked  distention 
of  the  abdomen,  and  often  distress  from  mechanical  interference  with 
the  diaplu-agm. 

Edema  of  the  legs  is  not  so  common,  but  may  occm'  in  consequence 
of  obstruction  from  pressure  of  the  ascitic  fluid  on  the  veins  which 
return  the  blood  from  the  lower  extremities.  Physical  exammation 
reveals  a  diminished  area  of  liver  dulness,  and,  as  a  rule,  enlargement 
of  the  spleen.  In  these  cases  death  is  due  to  exhaustion,  and  may  be 
preceded  by  drowsiness,  delirium,  and  coma. 

In  hypertrophic  cirrhosis,  jaundice  is  present  at  the  onset,  grows 
deeper  as  the  disease  progresses,  and  is  one  of  the  diagnostic  features. 
There  is  no  ascites.  Both  liver  and  spleen  are  enlarged.  The  course 
of  the  hypertrophic  is  more  rapid  than  that  of  the  atrophic  form  of 
cirrhosis,  and  the  children  aft'ected  usually  die  within  a  year  or 
eighteen  months. 

Diagnosis. — The  cardinal  features  in  the  diagnosis  of  atrophic 
cu'rhosis  are  the  decrease  in  the  size  of  the  liver  and  the  ascites.  In 
hypertrophic  cirrhosis  the  enlargement  of  the  liver  and  spleen  and 
deepening  jaundice  are  significant,  but  the  diagnosis  is  often  most 
difficult  and  is  frequently  made  only  at  postmortem. 

Prognosis. — In  most  cases  the  prognosis  is  unfavorable,  and  there 
is  certamly  no  possibility  of  curing  the  disease  and  restoring  the  liver 
to  normal;  but  in  some  instances  we  may  remove  the  cause  of  cirrhosis, 


CIRRHOSIS  OF  THE  LIVER  383 

and  thus  arrest  the  disease  before  the  hver  is  too  badly  damaged  to 
functionate  properly.  In  syphilitic  cirrhosis  the  outlook  is  thus 
made  favorable  if  antisyphilitic  treatment  be  instituted  early. 

Treatment. — In  all  but  syphilitic  cases  the  treatment  is  largely 
symptomatic,  since  little  can  be  done  to  restore  the  organ  to  its  normal 
state.  When  syphilis  is  suspected,  mercurial  inunctions  should  be 
given,  using  |  to  1  dram  of  mercurial  ointment  daily,  and  rubbing  it 
into  a  different  part  of  the  body  each  day. 

Mercury  should  also  be  administered  internally  in  the  form  of  gray 
powder,  dose  1  to  3  grains  three  times  a  day;  or  calomel  may  be  given, 
yV  to  i  of  a  grain  three  times  a  day.  It  is  advisable  to  continue  the 
mercurial  treatment  for  at  least  a  year,  and  potassium  iodide  should 
be  given  in  addition  in  1-  to  5-grain  doses  after  meals,  gradually 
increasing  the  dosage  to  the  point  of  tolerance. 

In  cirrhosis  from  other  causes  the  underlying  factor  should  be 
removed,  whenever  possible,  in  order  to  arrest  the  progress  of  the 
disease. 

These  children  are,  as  a  rule,  poorly  nourished  and  in  bad  health, 
consequently  an  attempt  must  be  made  to  build  up  their  general 
constitution  by  adequate  rest,  moderate  exercise,  plenty  of  fresh 
air,  and  frequent  bathing.  Particular  attention  should  be  paid  to 
the  diet,  which  must  be  nourishing  but  light  on  account  of  the  con- 
gestion of  the  gastric  and  intestinal  mucosa.  The  body  must  be  kept 
warm,  and  its  surface  never  allowed  to  become  chilled. 

If  relief  of  the  gastro-intestinal  symptoms  is  to  be  expected,  the 
gastric  congestion  must  be  removed,  and  this  is  best  accomplished 
by  giving  the  child  alkaline  mineral  waters  before  meals.  Carlsbad 
and  Vichy  are  the  best,  and  act  most  effectually  when  taken  hot;  in 
fact,  hot  water  is  of  so  much  value  when  taken  by  the  tumblerful 
before  meals  that,  in  cases  where  mineral  waters  cannot  be  procured 
on  account  of  their  cost,  plain  hot  water  should  be  taken  instead. 
Saline  purgatives  are  also  of  service  in  relieving  the  congested  stomach, 
and  sodium  phosphate,  10  to  20  grains,  or  magnesium  sulphate,  ^ 
to  2  drams,  may  be  taken  each  morning  in  hot  water. 

Besides  relieving  the  symptoms  due  to  congestion,  these  saline 
depletents  also  carry  off  ascitic  fluid;  but  it  may  be  necessary  to 
give  diuretics  as  well,  or  even  to  tap  the  abdomen  if  the  accumulation 
of  fluid  becomes  so  great  as  to  cause  mechanical  interference  with 
the  heart  action  or  the  diaphragm.  The  following  prescription  for 
a  diuretic  has  proven  of  service: 

I^ — Potassii  bitartratis Siiss 

Syrupi  limonis, 

Aqua aa     fgj 

Sig. — 5J.  every  three  hours  in  water. 

If  the  heart  becomes  weak  and  stimulation  is  needed,  strychnine 
sulphate,  ^iu  to  2^-0,  and  atropine  sulphate,  g-i^  to  t^u  of  a  grain,  may 
be  given  by  hypodermic;  but  if  the  cardiac  weakness  is  due  to  over- 


384  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

action  caused  by  the  pressure  of  the  ascitic  fluid  tapping  should  be 
resorted  to. 

To  tap  the  abdomen  of  a  child,  the  little  patient  should  be  held 
in  a  sitting  posture  until  the  trocar  has  penetrated  the  abdominal 
wall.  The  fluid  should  be  drained  oft'  very  slowly,  a  little  being  allowed 
to  remain.  Before  plunging  in  the  needle,  care  should  be  taken  to 
see  that  the  bladder  is  empty,  since  this  organ  has  not  infrequently 
been  punctured  while  tapping  the  abdomen. 

In  many  cases  the  fluid  returns  rapidly  and  tapping  is  again  neces- 
sary. Laparotomy  has  recently  been  advocated  as  a  possible  means 
of  preventing  this  recurrence  of  ascitic  fluid. 

AMYLOID   LIVER. 

Amyloid  degeneration,  or  lardaceous  disease,  of  the  liver,  although 
quite  rare  during  childhood,  sometimes  occurs  in  association  with 
amyloid  disease  of  other  organs,  and  is  characterized  by  an  infiltra- 
tion of  all  the  tissues  of  the  liver  with  amyloid  material.  The  infil- 
tration begins  in  the  walls  of  the  smaller  arteries,  then  invades  the 
cells  and  capillaries  and,  in  extreme  cases,  permeates  even  the  con- 
nective tissue. 

Etiology. — Tuberculosis,  s\'phLlis,  and  rachitis  are  the  diseases 
most  often  accompanied  by  lardaceous  infiltration.  The  usual  cause 
of  amyloid  liver,  however,  is  continued  suppuration,  especially  that 
of  chronic  bone  disease,  and  it  is  occasionally  observed  in  association 
with  tuberculosis  of  the  hip  and  Pott's  disease.  Pulmonary  tuber- 
culosis does  not,  as  a  rule,  cause  amyloid  disease;  but  other  chronic 
suppurative  processes  in  the  lung,  such  as  empyema  and  bronchiectasis, 
are  recognized  factors  in  the  formation  of  lardaceous  substance. 
Syphilis  of  the  bone,  pernicious  anemia,  leukemia,  and  the  infectious 
diseases  are  also  predisposing  causes. 

Pathology. — The  amyloid  liver  is  enlarged,  hard,  firm,  and  heavier 
than  the  normal  organ.  The  surface  has  a  waxy  appearance,  and  on 
section  the  liver  tissue  resembles  the  fat  of  bacon.  When  exammed 
under  the  microscope,  degeneration  of  the  liver  cells  is  apparent, 
which  has  been  caused  by  deposits  of  an  amyloid  substance  resembling 
starch  granules;  occasionally  there  is  also  fatty  infiltration. 

If  a  section  of  the  aft'ected  liver  tissue  is  pamted  with  a  weak  solu- 
tion of  iodine,  it  turns  to  a  mahogany-red  color,  and  on  adding  sul- 
phuric acid  the  color  again  changes  to  violet  or  blue.  When  the  liver 
is  thus  aft'ected,  deposits  of  amyloid  substance  may  also  be  found  in 
the  spleen  and  kidneys. 

Symptoms. — In  these  cases  there  are  no  typical  symptoms  referable 
to  the  liver  aside  from  the  marked  enlargement,  which  can  be  demon- 
strated by  physical  examination  of  the  child.  An  increasing  pallor  _ 
of  the  skin,  with  edema  and  puffiness  about  the  eyes,  is  a  constant 
feature,  but  there  is  no  jaundice.  Occasionally  gastro-intestinal  dis- 
turbances appear,  with  nausea,  vomiting,  and  diarrhea.    The  kidne\'s 


FATTY  LIVER  385 

are  usually  involved  to  such  an  extent  that  the  urine  is  increased  in 
amount  and  contains  albumin  and  hyalin  casts. 

In  the  terminal  stages  of  the  disease,  ascites  and  edema  may  be 
present,  and  the  child  become  extremely  emaciated  from  progressive 
wasting.  On  physical  examination  both  the  liver  and  spleen  are 
found  to  be  enlarged.  The  enlargement  of  the  liver  is  uniform,  the 
edges  are  rounded,  the  surface  of  the  organ  is,  smooth.  As  a  rule,  there 
is  no  tenderness. 

Diagnosis. — This  is  readily  made  when  we  find  in  a  child  enlarge- 
ment of  the  liver  with  a  chronic  suppurating  process  elsewhere  in  the 
body,  and  when  there  is  accompanying  enlargement  of  the  spleen  and 
albuminuria,  but  no  jaundice. 

Prognosis. — In  children  the  prognosis  of  lardaceous  disease  of  the 
liver  is,  as  a  rule,  unfavorable  because  of  the  gravity  of  the  primary 
disease.  When  it  is  possible  to  remove  its  cause,  improvement  in  so  far 
as  this  is  indicated  by  a  cessation  of  symptoms  may  occur,  but  it  is 
questionable  whether  the  liver  tissue  ever  returns  to  normal. 

Treatment. — Aside  from  the  removal  of  the  cause,  the  treatment 
of  lardaceous  disease  is  largely  symptomatic.  If  syphilis  is  the  under- 
lying factor  this  disease  should  be  treated.  In  those  cases  associated 
with  chronic  suppuration,  the  suppurative  process  must  be  healed, 
if  possible.  Since  the  general  health  of  these  children  is  usually  poor, 
they  should  be  put  upon  a  light  nourishing  diet,  take  moderate  exer- 
cise, and  have  adequate  rest  and  plenty  of  fresh  air.  Tonics  containing 
iron,  such  as  the  syrup  of  ferrous  iodide,  dose  5  to  20  drops  three  times 
a  day,  may  be  given;  and,  if  the  circulation  be  poor,  also  1  to  3  drops 
of  digitalis  after  meals. 

FATTY   LIVER. 

This  disease  is  common  during  childhood,  and  is  the  cause  of  many 
cases  of  enlargement  of  the  liver.  It  may  be  due  either  to  fatty  infil- 
tration or  fatty  degeneration  of  the  liver  cells,  which  are  more  or  less 
completely  converted  into  fat.  When  fatty  infiltration  takes  place, 
fat  droplets  are  found  within  the  liver  cells  which  become  larger,  push 
aside  the  protoplasm,  and  cause  it  to  disappear  by  interfering  wath 
its  nutrition.  In  fatty  degeneration  the  protoplasm  of  the  liver  cell 
disintegrates,  the  nucleus  loses  its  staining  power,  and  fat  droplets 
representing  the  principal  part  of  the  residue  fill  the  cell.  Of  these  two 
conditions  fatty  infiltration  is  by  far  the  more  common  during  childhood. 

Etiology. — Fatty  infiltration  takes  place  in  children  who  are  overfed, 
and  who  indulge  in  an  excessive  amount  of  sweets  and  pastry;  to  a 
certain  extent,  too,  it  is  present  in  every  case  of  adiposity.  Children 
in  cachectic  states  in  which  oxidation  of  fat  is  interfered  wdth  have  a 
fatty  liver,  and  this  condition  is  also  associated  wdth  gastro-intestinal 
indigestion,  tuberculosis,  rachitis,  and  w^asting  diseases.  Fatty  degen- 
eration of  the  liver  occurs  as  a  result  of  the  action  of  various  toxins 
upon  the  liver  cells,  and  is  seen  in  phosphorus  and  chloroform  poison- 
ing; in  acute  infections,  such  as  diphtheria,  measles,  scarlet  fever, 
25 


386  DISEASES  OF  THE  GASTRO-INTESTINAL   TRACT 

smallpox,  typhoid  fever,  miliary  tuberculosis,  acute  leukemia,  and 
bronchopneumonia;  also  in  acute  yellow  atrophy  of  the  liver,  con- 
genital syphilis,  and  chronic  tuberculosis. 

Pathology. — It  has  been  estimated  that  more  than  one-half  of  all 
the  children  who  come  to  autopsy  have  an  abnormal  deposit  of  fat 
in  the  liver.  In  fatty  infiltration  the  liver  is  greatly  enlarged  in  all 
its  dimensions,  is  soft,  and  has  a  smooth  surface.  It  is  lighter  in  color 
than  the  normal  organ,  owing-  to  the  presence  of  fat,  and  also  to 
anemia  of  the  liver.  On  cross-section  fat  droplets  may  be  expressed 
from  the  cut  surfaces  with  ease,  and  on  microscopic  examinatiqn 
the  fat  content  of  the  liver  cell  is  readily  detected. 

Symptoms. — There  are  no  subjective  symptoms  of  faj:ty  liver,  and 
unless  revealed  by  palpation  and  percussion  the  condition  may  not 
be  suspected.  The  area  of  liver  dulness  will  be  found  to  be  increased, 
but  not  so  greatly  as  in  amyloid  disease.  The  edge  of  the  liver  can 
usually  be  palpated,  and  is  smooth  and  rounded.  In  the  latter  stages 
of  fatty  degeneration  the  liver  becomes  much  smaller  than  usual, 
owing  to  the  rapid  destruction  of  liver  tissue. 

Prognosis. — In  fatty  infiltration  the  prognosis  depends  on  the 
underlying  factor,  and  if  the  cause  can  be  removed  the  liver  returns 
to  normal.  Fatty  degeneration  is  usually  secondary  to  some  grave 
condition,  and  generally  proves  fatal. 

Treatment. — The  treatment  is  for  the  most  part  that  of  the  primary 
disease.  In  fatty  infiltration  due  to  overfeeding,  it  is  possible  to  reduce 
the  size  of  the  liver  by  regulating  the  diet,  for  the  exclusion  of  all 
carbohydrates  will  stop  to  a  great  extent  the  formation  and  deposi- 
tion of  fat.  Abdominal  massage  and  an  adequate  amount  of  outdoor 
exercise  are  also  beneficial  in  these  cases. 

TUBERCULOSIS    OF   THE   LIVER. 

Tuberculosis  of  the  liver  is  not  uncommon  in  children  afi^ected  with 
general  tuberculosis,  but  rarely  causes  any  symptoms  except  enlarge- 
ment of  that  organ,  which  is  usually  attributed  to  some  other  cause. 
Primary  lesions  in  the  liver  need  hardly  be  considered ;  but  the  infec- 
tion may  be  carried  into  the  blood  stream  from  the  lung  and  reach 
the  liver  through  the  hepatic  arteries,  or  may  be  carried  to  the  portal 
circulation  in  intestinal  tuberculosis. 

It  is  also  possible  for  tuberculous  infection  to  be  conveyed  to  the 
liver  by  way  of  the  bile  ducts  or  lymphatics.  In  some  cases  in  which 
the  primary  focus  is  in  the  lung,  pulmonary  symptoms  may  be  latent 
until  the  disease  is  well  established. 

Pathology. — The  miliary  type  of  tuberculosis  is  the  most  common. 
Here  the  liver  is  usually  enlarged,  yellow  in  color,  its  surface  studded 
with  miliary  tubercles,  which  are  also  scattered  throughout  the  interior 
of  the  organ.  They  are  most  abundant  within  the  lobules,  and  show 
a  tendency  to  cluster  about  the  bile  ducts.  In  more  advanced  stages 
of  the  disease  these  tubercles  form  cyst-like  cavities  ranging  in  size 


SYPHILIS  OF  THE  LIVER  387 

from  a  pin  head  to  a  large  pea.  Large  tubercles  are  more  frequently 
found  in  the  liver  during  childhood  than  they  are  in  adult  life,  but 
are  extremely  rare. 

Diagnosis. — There  is  little  opportunity  to  diagnose  a  tuberculous 
liver  unless  a  large  tubercle  forms  close  to  the  surface  and  gives  rise 
to  a  palpable  tumor.  Here  the  treatment  is  that  of  tuberculosis  else- 
where in  the  body.  Cirrhotic  changes  are  occasionally  attributed  to 
chronic  tuberculosis  of  the  liver,  and  occur  as  its  sequel.  Tuberculosis 
of  the  bile  ducts  occurs  in  association  with  tuberculous  infection  of 
the  peritoneum  and  intestines,  the  cases  being  relatively  more  numer- 
ous in  children  than  in  adults.  It  presents  no  characteristic  symptoms, 
and  is  commonly  diagnosed  only  at  autopsy. 

Treatment. — The  treatment  is  that  of  general  tuberculosis. 

SYPHILIS    OF    THE    LIVER. 

Syphilitic  infection  of  the  liver  is  not  uncommon.  The  majority 
of  cases  occur  in  children  who  suffer  from  congenital  lues,  although 
syphilis  acquired  during  childhood  may  also  result  in  syphilitic  hepa- 
titis. The  acquired  form  differs  from  the  congenital  in  its  limited 
distribution,  the  infection  being  carried,  as  a  rule,  by  the  hepatic 
artery,  while  in  congenital  lues  the  syphilitic  virus  is  transmitted  by 
the  umbilical  veins,  and  diffused  throughout  the  liver. 

Most  cases  of  syphilis  of  the  liver  are  observed  in  newborn  or  pre- 
mature infants  and,  at  the  latest,  become  apparent  during  the  first 
few  weeks  of  life.  Exceptionally,  cases  are  reported  in  which  the 
disease  did  not  manifest  itself  in  the  liver  until  after  the  fifth  or  sixth 
year,  but  these  are  uncommon. 

Pathology. — In  congenital  cases,  as  a  rule,  the  liver  is  enlarged  at 
birth,  and  has  a  smooth  but  pale  or  mottled  surface.  It  is  much 
harder  and  firmer  than  the  normal  organ,  and  distinctly  resists  the 
knife  when  an  attempt  is  made  to  section  it.  On  section  the  cut  sur- 
face is  smooth  and  shining,  and  usually  reveals  many  small  gray  areas, 
commonly  called  miliary  gummata,  which  represent  a  diffused  cell- 
growth  throughout  the  organ.  This  diffuse  infiltrative  form  is  most 
common;  but  occasionally  there  may  be  scattered,  throughout  the 
liver,  localized  gummatous  areas  of  much  greater  size,  resembling  the 
adult  form  of  syphilitic  hepatitis,  although  the  gummata  are  usually 
smaller. 

Adhesions  also  are  frequently  found  about  the  capsule  of  the  liver; 
occasionally  the  liver  is  adherent  to  adjacent  organs  or  tissues.  In 
the  diffuse  infiltrative  form  there  is  observed  under  the  microscope 
a  considerable  growth  of  connective-tissue  cells  at  the  expense  of 
functionating  liver  tissue.  Later  on  this  causes  the  cirrhotic  changes 
not  uncommon  in  syphilitic  hepatitis.  Enlargement  of  the  spleen  is 
also  a  common  finding  in  syphilis  of  the  liver. 

Symptoms. — The  infants  affected  are  often  premature  or  stillborn, 
and  the  enlarged  liver  can  usually  be  outlined  on  examination  of  the 


388  DISEASES  OF   THE  GASTRO-IXTESTINAL   TRACT 

abdomen.  If  the  child  is  aHve  at  birth,  the  hver  may  then  be  found 
to  be  enlarged,  or  it  may  become  larger  within  the  first  few  weeks  of 
life.  I\Ior cover,  jamidice  and  the  concomitant  signs  and  s\Tnptoms  of 
syphilis  are  usually  present. 

The  nutrition  of  syphilitic  infants  is  usually  below  par,  and  it  is 
generally  quite  easy  to  feel  the  firm  smooth  edge  of  the  enlarged  liver, 
and  to  detect  the  spleen  which  is  also  increased  in  size.  \'\Tien  con- 
genital syphilis  does  not  affect  the  liver  until  later  childhood,  ascites 
is  not  unusual,  in  addition  to  those  symptoms  observed  in  mfancy. 

Diagnosis. — In  the  majority  of  cases  of  congenital  syphilis  the  diag- 
nosis is  easy.  It  is  based  upon  enlargement  of  the  liver  m  a  child  with 
inherited  lues.  The  Wassermann  reaction  and  the  results  of  mercurial 
treatment  may  be  confirmatory  indications,  but  are  scarcely  necessary. 

Prognosis. — This  depends  to  a  great  extent  upon  the  nature  of  the 
syphilitic  process.  It  is  less  favorable  in  the  diffuse  infiltrative  form 
which  may  go  on  to  cirrhosis  than  in  the  gummatous  type.  From  our 
observations  it  would  seem  that  recovery  is  to  be  expected  in  the 
majority  of  cases. 

Treatment. — ^Mercury  should  be  administered  from  the  time  the 
diagnosis  is  first  made  until  all  evidence  of  syphilis  has  disappeared. 
After  this  it  may  be  given  at  frequent  intervals  for  two  or  tliree  years. 
Inunctions  are  especially  valuable  in  mfants,  and  15  to  30  grains  of 
mercurial  omtment  should  be  rubbed  into  the  skin  each  day,  choosing 
a  difterent  area  for  the  inunction  from  day  to  day,  the  abdominal 
wall,  axillse,  and  groins  being  preferable  sites. 

Calomel,  in  a  dose  of  f  to  J  of  a  grain,  is  the  best  form  of  mercury 
to  give  by  mouth,  although  the  gray  powder  is  also  sometimes  given 
in  1-  to  3-gram  doses.  Iodides  are  also  beneficial  when  combined  with 
mercurial  treatment,  and  may  be  admmistered  as  potassium  iodide, 
1  to  5  drops  of  the  saturated  solution,  or  5  to  10  drops  of  the  syrup  of 
ferrous  iodide.  If  stomatitis  (mercurial)  is  threatened,  a  3  per  cent. 
solution  of  potassium  chlorate  should  be  used  as  a  mouth  wash. 

A  syphilitic  infant  should  be  allowed  to  nurse  from  its  syphilitic 
mother;  its  general  health  should  be  carefully  attended  to.  Older 
children  should  be  put  on  a  full  nourishing  diet,  take  plenty  of  outdoor 
exercise,  and  have  the  advantage  of  all  other  h\-gienic  measures  for 
the  improvement  of  the  general  health. 

TUMORS    OF    THE   LIVER. 

Xew  growths  of  the  liver  are  extremely  rare  in  children,  but  both 
malignant  and  benign  tumors  have  been  observed.  ^Malignant  growths 
are  generally  secondary,  the  primary  focus  bemg,  as  a  rule,  in  the 
kidney.  Both  carcinoma  and  sarcoma  are  observed,  adenocarcinomata 
being  the  most  frequent. 

Symptoms. — Jaundice  and  enlargement  of  the  liver  are  the  most 
common  symptoms.  On  palpation  the  surface  of  the  liver  feels  very 
irregular  and  uneven,  and  nodular  tumors  may  be  detected.    In  some 


DISEASES  OF  THE  PANCREAS  389 

cases  the  tumor  attains  an  enormous  size,  and  may  entirely  fill  the 
abdominal  cavit\'. 

Treatment. — This  is  of  no  avail.  It  consists  mainly  of  attempts  to 
relieve  the  discomfort,  and  to  prolong  the  life  of  the  patient.  Death 
usually  occurs  in  from  two  to  six  months. 

The  benign  tumors  of  the  liver  are  the  adenoma,  angioma,  myxoma, 
lipoma,  and  fibroma.    They  are  very  rare  in  children. 

CYSTS    OF    THE   LIVER. 

Three  varieties  of  cyst  may  be  found  in  the  liver;  i.  e.,  simple  reten- 
tion cysts  caused  by  obstruction  of  a  small  bile  duct,  congenital  cystic 
disease  of  the  liver,  and  hydatid  disease  of  the  liver. 

Hydatid  cyst,  caused  by  the  invasion  of  the  liver  by  the  embryo 
or  larva  of  the  Taenia  echinococcus,  is  quite  rare  in  this  country.  These 
cysts,  if  small,  produce  no  symptoms;  but  as  they  increase  in  size 
the  liver  slowly  enlarges,  perhaps  considerably,  and  feels  heavy  and 
uncomfortable.  Jaundice  may  or  may  not  appear,  and  there  is  usually 
no  ascites.  Hydatid  fremitus,  which  is  a  trembling  felt  by  the  finger 
when  a  superficial  c}'st  is  tapped,  is  characteristic. 

Diagnosis. — The  diagnosis  may  sometimes  be  made  from  these 
symptoms,  but  it  may  be  confirmed  by  tapping  a  cyst,  and  searching 
for  the  booklets  of  the  embryo.  Unilocular  cysts  are  most  common 
in  children. 

Treatment. — Aspiration  may  cause  the  cyst  walls  to  collapse  tem- 
porarily, but  the  cyst  is  apt  to  fill  up  again  with  serum;  therefore 
laparotomy  and  removal  of  the  cyst  are  recommended.  In  children 
rupture  of  these  cysts  is  especially  liable  to  occur,  spreading  then* 
contents  throughout  the  peritoneal  cavity,  and  resulting  in  multiple 
cyst  formation  within  the  abdomen.  If  possible  the  cyst  should  be 
removed  whole;  if  this  can  not  be  done,  the  cyst  wall  should  be 
attached  to  the  edge  of  the  incision,  and  free  drainage  thus  secured. 
All  cases  in  which  there  is  suppuration  should  also  be  freely  drained. 


DISEASES   OF  THE   PANCREAS. 

The  pancreas  is  rarely  diseased  during  childhood,  but  both  acute 
and  chronic  pancreatitis  are  occasionally  observed,  and  tuberculosis 
and  syphilis  of  the  pancreas  have  been  reported. 

Acute  Pancreatitis. — Acute  pancreatitis  is  most  frequently  a  com- 
plication of  mumps,  the  symptom  appearing  within  a  week  after  the 
onset  of  the  parotitis,  and  usually  subsiding  within  a  week  or  ten  days. 
There  is  epigastric  pain,  with  vomiting  and  diarrhea.  On  palpating 
the  abdomen  tenderness  may  be  perceptible  in  the  epigastrium.  This 
complication  of  mumps  is,  as  a  rule,  not  serious,  and  calls  for  no  par- 
ticular treatment. 


390  DISEASES  OF   THE  GASTRO-INTESTINAL   TRACT 

Chronic  Pancreatitis. — Chronic  pancreatitis  is,  in  most  instances, 
a  result  of  si^-philis,  but  may  be  caused  by  tuberculosis,  or  accompany 
diabetes  mellitus.  The  symptoms  are  by  no  means  typical,  although 
there  is  frequently  an  excess  of  fat  in  the  stools. 

Tuberculosis  of  the  Pancreas. — Tuberculosis  of  the  pancreas  occurs 
less  rarely  in  children  than  in  adults,  and  is  always  considered  as  a 
secondary  affection,  which  has  either  extended  from  adjacent  lymph 
glands,  or  been  carried  to  the  pancreas  in  the  blood  stream  from  more 
distant  parts  of  the  body.  It  may  be  either  acute  or  chronic;  but  the 
symptoms  are  not  at  all  characteristic,  and  the  diagnosis  is  rarely 
made. 


CHAPTER  XIV. 
DISEASES  OF  THE  RESPIRATORY  TRACT. 

ANOMALIES. 

Congenital  absence  or  rudimentary  conditions  of  the  nose  are 
rarely  met  with,  but  it  is  not  uncommon  for  an  infant  to  be  born 
with  its  nasal  passages  considerably  narrowed  or  occluded.  If  the 
latter  defect  is  bilateral,  it  must  be  immediately  corrected,  or  sudden 
death  from  asphyxia  may  result,  since  a  baby  never  instinctively 
breathes  through  its  mouth. 

In  later  life,  mouth-breathing  is  injurious  because  it  interferes  with 
Nature's  provision  for  the  filtration,  warming,  and  proper  moistening 
of  the  air  during  its  passage  through  the  nasal  cavities,  consequently 
the  delicate  structures  of  the  pharynx,  the  larynx,  the  trachea,  the 
bronchi,  and  the  lungs  suffer. 

The  narrow  nasal  passage  may  be  still  more  contracted  and  respira- 
tion greatly  obstructed  by  deformity  of  the  turbinated  bones,  by  a 
hypertrophied  condition  of  the  mucous  membrane  covering  them,  or 
by  a  deflected  septum  due  to  trauma  or  asymmetrical  bony  develop- 
ment of  the  base  of  the  skull  or  upper  maxilla,  or  to  a  high  V-shaped 
palate. 

Any  difficulty  in  breathing  interferes  with  proper  nursing  and  feed- 
ing, and,  no  matter  from  what  cause,  may  lead  to  faulty  thoracic 
development.  W.  P.  Parsons  has  called  attention  to  the  fact  that  an 
anterior  nasal  obstruction  produces  deformity  of  the  maxilla,  and  a 
posterior  obstruction  causes  depression  and  widening  of  the  bridge 
of  the  nose. 


DISEASES   OF  THE  NASOPHARYNX. 


ACUTE    RHINITIS. 

This  affection,  familiarly  known  as  "a  cold  in  the  head,"  is  very 
common  in  nurslings  and  throughout  infancy.  The  swollen  mucous 
membrane  more  or  less  completely  blocks  the  nasal  passages,  while 
the  labored  breathing  induces  great  fatigue,  and  interferes  with  suck- 
ing as  well  as  with  sleep.  Moreover,  the  inflammation  is  liable  to 
spread  to  the  conjunctivae,  the  nasopharynx,  the  tonsils,  and,  through 
the  patulous  opening  of  the  Eustachian  tube,  to  the  middle  ear.     It 


392  DISEASES  OF  THE  RESPIRATORY  TRACT 

often  gives  rise  to  cough,  which  is  sharp  and  irritating  when  the 
pharynx  is  affected,  and  croupy  when  the  larynx  is  involved.  By 
extension,  the  mflammation  may  produce  tracheitis,  bronchitis,  or 
bronchopneumonia . 

Etiology. — The  exciting  cause  is,  no  doubt,  of  bacterial  origin,  the 
staphylococcus,  pneumococcus,  streptococcus,  and  the  influenza 
bacillus  having  been  found  in  the  secretions,  as  well  as  the  Diplococcus 
intracellularis. 

Infectious  diseases,  such  as  measles,  scarlet  fever,  whooping-cough, 
grippe,  and  influenza  are  often  preceded  or  accompanied  by  coryza;the 
latter,  even  when  exceedingly  mild,  may  be  diphtheritic.  In  view  of 
these  numerous  possible  inciting  causes  and  in  view  of  the  fact  that 
many  varieties  of  bacilli  may  be  and  are  actually  found  on  the  healthy 
nasal  mucous  membrane,  it  is  difficult  to  point  to  a  specific  cause  and 
to  say  definitely  which  of  the  microbes  are  onh-  accidentally  present. 
Under  normal  conditions  the  healthy  nasal  mucosa  evidently  resists 
the  infection,  and  it  is  only  when  this  natural  immunity  is  reduced  or 
destroyed  by  a  depression  of  the  local  or  the  general  resistance  that 
rhinitis  develops.  Some  factors  that  lead  to  such  a  lowered  resistance 
are:  exposure  to  cold  and  dampness,  careless  bathing,  wet  feet,  the 
inhalation  of  irritating  fumes  or  of  dry,  dust-laden,  or  superheated 
air,  sudden  changes  in  the  weather — especially  during  the  spring  and 
winter  months — and  certainly  malnutrition,  anemia,  and  a  generally 
run-down  condition.  The  specific  rhinitis  of  syphilis  and  of  tuber- 
culosis is  closely  associated  with  the  symptoms  of  these  diseases  and 
is  fully  discussed  under  those  subjects. 

Symptoms. — The  symptoms  include  the  ordinary  phenomena  of 
mucomembranous  inflammations,  sneezing  as  an  early  symptom, 
swelling,  redness,  and  increased  secretion.  After  a  period  of  stuffiness, 
the  nasal  discharge  becomes  profuse  and  watery,  later  thicker,  muco- 
purulent, or  piu-ulent.  It  is  always  purulent  in  the  gonococcic,  scax- 
latinal,  and  diphtheritic  varieties,  and  often  irritates  or  erodes  the 
nasal  openings  or  the  neighboring  parts.  In  older  children  there  is 
slight  if  any  fever,  but  should  the  inflammation  spread  to  the  pharynx, 
the  tonsils,  or  the  middle  ear,  the  temperature  is  high  and  continuous. 
The  cervical  lymph  nodes  may  swell  and  become  painful,  with  ner- 
vousness, sleeplessness,  lassitude,  and  headache  as  the  usual  con- 
comitants. Uncomplicated  cases  in  older  children  run  an  uneventful 
course,  recovery  taking  place  in  three  to  five  days;  but  in  young 
infants  the  difficult  breathing  and  eventually  the  cough  interfering 
with  sleep  and  nutrition,  their  naturally  weak  resistance  is  still  more 
reduced,  and  the  risk  of  further  spread  and  dangerous  complications 
is  increased. 

Where  there  is  a  purulent  or  an  occasionally  blood-tinged  discharge 
accompanied  by  fever,  there  is  great  danger  of  overlooking  the  possi- 
bility of  diphtheria.  The  disastrous  consequences  of  such  an  over- 
sight are  self-evident.  Therefore,  as  long  as  a  careful  bacteriologic 
examination  has  not  demonstrated  the  absence  of  the  Klebs-LoefHer 


ACUTE   RHINITIS  393 

bacillus,  the  patient  should  be  given  the  benefit  of  the  doubt  and 
should  receive  a  dose  of  antitoxin. 

Treatment. — Considering  the  ease  with  which  the  infection  spreads 
to  the  bronchi  and  the  lungs  of  a  delicate  infant,  thorough  and  early 
treatment  seems  especially  important.  Much  can  be  done  in  the 
way  of  prophylaxis  by  providing  proper  and  seasonable  clothing — 
neither  too  much  nor  too  little,  a  nutritious,  easily  digested  diet,  pure 
non-irritating  air,  and  by  judicious  hardening  begun  in  summer  with 
an  open-air  life  and  the  daily  cold  sponge.  Coddling,  the  use  of  chest 
protectors,  overheating  the  room  or  the  bed  during  the  colder  season, 
should  be  avoided,  and  exposure  to  infection  by  contact  with  persons 
suffering  with  catarrh  or  colds  carefully  guarded  against. 

Active  treatment  in  severe  cases  will  naturally  depend  upon  the 
condition  of  the  patient  and  the  character  of  the  attack.  As  a  rule 
children  should  be  kept  in  the  house  in  well-ventilated  rooms,  at  a 
temperature  of  60°  to  70°  F.  A  simple  cathartic — castor  oil  or  calomel 
and  salts — causes  depletion,  rids  the  gastro-intestinal  canal  of  the 
swallowed  secretion,  and  prevents  auto-intoxication  from  the  bowels. 
Mild  diaphoretics,  fresh  warm  air,  moistened  occasionally  with  a 
spray,  warm  drinks  of  water  or  lemonade  are  useful  and  agreeable  to 
the  patient.  During  the  early  stage,  |  to  ^e  of  a  grain  of  sodium  chloride 
crystals  in  each  nostril  relieves  congestion  by  causing  a  copious  dis- 
charge; for  older  children,  we  recommend  an  alkaline  spray — saline, 
Dobell's  solution,  or  one  containing  1  per  cent,  of  the  chloride,  bicar- 
bonate, and  biborate  of  sodium  combined — to  clear  away  the  abnormal 
secretion,  to  be  followed  by  a  simple  protective,  such  as  camphor, 
gr.  1,  menthol,  gr.  1,  liq.  petrol.  5j>  applied  to  the  mucous  membrane. 
In  children  under  three  years  this  is  best  done  by  instilling  a  few  drops 
into  each  nostril  several  times  a  day.  Vaseline  or  any  mild  ointment 
will  protect  the  lips  and  nostrils  from  excoriation.  Adrenalin,  1  to 
1000  solution,  is  recommended  where  there  is  much  obstruction  from 
an  acutely  congested  mucous  membrane,  but  cocain  hydrochloride, 
gr.  3,  to  the  ounce,  added  to  any  of  the  above  prescriptions  will  prove 
almost  equally  efficacious.  In  severe  cases,  painting  or  spraying  with 
25  per  cent,  argyrol  after  irrigation  with  warm  saline,  proves  of  value 
if  done  early  enough.  Generally  speaking,  little  can  be  done  once  the 
secretion  has  become  profuse,  but  should  it  continue  so  for  any  length 
of  time,  astringents  are  indicated — a  2  per  cent,  solution  of  formalin, 
although  painful,  often  gives  very  good  results.  Kyle  recommends 
fiuidextract  hamamelis  1  fluidram,  fluidextract  hydrastis,  |  dram, 
water  enough  to  make  2  ounces,  as  a  cleansing  solution  and  an  anti- 
septic, a  few  drops  to  be  instilled  into  each  nostril  morning  and  night. 

A  run-do WTL  condition,  anemia,  or  malnutrition,  predisposes  the  child 
to  infection  of  any  kind  and  should  be  treated.  Repeated  attacks  of 
rhinitis  may  often  be  traced  to  carelessness  in  bathing  the  infant; 
or  they  may  be  caused  by  the  presence  of  adenoids  or  of  a  foreign 
body,  which,  interfering  with  nasal  drainage,  produces  a  certain  amount 
of  irritation  and  congestion.    No  permanent  results  can,  of  course,  be 


394  DISEASES  OF   THE  RESPIRATORY  TRACT 

expected  unless  the  cause  be  removed.  The  treatment  of  the  snuffles 
of  syphiHs,  the  coryza  of  tuberculosis,  hay-fever,  diphtheria,  measles, 
etc.,  is  discussed  under  these  respective  diseases. 

CHRONIC   RHINITIS. 

This  rather  uncommon  affection  in  infants  and  young  children 
is  usually  spoken  of  either  as  hypertrophic  or  atrophic,  depending 
upon  the  thickness  of  the  nasal  mucous  membrane.  Many  observers 
consider  the  latter  to  be  merely  the  natural  consequence — the  retro- 
gressive stage — of  the  preceding  hyperplasia.  In  fact,  the  Schneiderian 
membrane  may  show  patches  of  both  conditions  in  the  same  patient. 

Hypertrophic  rhinitis  is  characterized  by  a  cushion-like  swelling 
of  the  mucous  membrane  lining  the  nasal  cavity,  especially  of  the 
inferior  turbinated  bones.  It  rarely  follows  the  acute  forms  of  coryza, 
but  accompanies  scrofula  and  chronically  enlarged  tonsils  and  adenoids. 
The  patients  grow  better  and  again  worse  with  every  change  from 
warm  to  cold  weather. 

Symptoms. — There  is  usually  some  mucopurulent  inoffensive  dis- 
charge which  gathers  particularly  in  the  inferior  meatus  and  often 
flows  backward  into  the  pharynx  causing  a  teasing  cough  or  neces- 
sitating frequent  clearing  of  the  throat.  Any  slight  exposure,  or  the 
onset  of  the  cold  season  increases  the  trouble.  The  nose,  alternately 
one  or  the  other  side,  seems  occluded;  at  all  events,  the  swollen  tur- 
binals,  together  with  the  usually  coexisting  adenoids,  cause  mouth- 
breathing,  especially  at  night.  This  in  turn  diminishes  the  appetite, 
disturbs  the  sleep,  and  creates  a  tendency  to  catarrh  of  the  pharynx 
and  the  lower  air  tubes.  A  nasal  voice,  vertigo,  migraine,  unilateral 
headache,  and  ear  trouble  are  perhaps  the  most  frequent  accompany- 
ing symptoms. 

Treatment. — In  addition  to  what  has  been  said  about  treatment  of 
the  acute  form,  it  is  necessary  to  ascertain  and  remove  the  cause  that 
directly  or  indirectly  is  affecting  the  secretions  or  the  circulation. 
Adenoids  or  foreign  bodies  should  be  removed,  and  deformities  of  the 
nasal  structure  corrected  by  operation.  Among  other  causative 
factors  in  children  from  ten  to  fifteen  years  of  age  are:  engorgement 
of  the  turbinals  at  puberty,  or  occasionally  mental  excitement,  sudden 
changes  in  temperature,  automobiling,  irritant  vapors,  and  gastro- 
intestinal disturbances.  In  the  scrofulous  child  the  nasal  condition 
will  improve  with  the  use  of  tonics,  malt,  cod-liver  oil,  iron,  and  nour- 
ishing food — while  mountain  or  sea  air  will  prove  an  additional  advan- 
tage. The  improvement  of  the  general  health — and  the  proper  regime 
— often  does  more  for  recovery  than  local  remedies,  but  the  latter 
must  frequently  supplement  the  former. 

For  the  very  young  child  it  is  best  to  avoid  nasal  douches  and 
inspection,  but  for  older  children  a  cleansing  solution  may  be  used 
— Dobell's,  half  strength — to  be  followed  by  a  stimulating  or  astringent 
lotion,  according  to  the  special  requirements  of  the  case. 


EPISTAXIS  395 

ATROPHIC   RHINITIS. 

In  atrophic  rhinitis,  the  nasal  mucosa  is  thin  and  pale,  and  the 
cylindrical  cell  lining,  especially  of  the  inferior  turbinals,  undergoes 
retrogressive  squamous  epithelial  proliferation.  The  air-passages  of 
the  nose  thus  become  dilated,  the  secretion  diminishes  and  changes 
its  character,  and  a  tenacious,  greenish-yellow  discharge,  liable  to 
form  crusts,  clings  to  the  walls  of  the  nasal  cavities,  where  it  decom- 
poses and  emits  a  very  strong  and  peculiar  fetor.  Fortunately  for 
the  victim,  his  sense  of  smell  is  usually  lost.  An  accompanying 
chronic,  dry  pharyngitis  frequently  adds  to  the  distress  of  the  patient. 

As  to  the  etiology,  we  lack  definite  knowledge.  It  seems  certain 
that  it  is  not  due  to  syphilis  although  a  specific  microorganism  may 
possibly  be  a  causative  factor,  while  some  connection  with  tuber- 
culosis has  lately  been  emphasized.  The  disease  occurs  in  families, 
preferably  in  girls,  but  rarely  before  the  age  of  ten  or  twelve  years. 

Treatment. — When  the  mucous  membrane  is  merely  atrophied,  it 
can  be  restored  to  normal,  but  the  outlook  is  less  hopeful  when  actual 
degeneration  has  taken  place.  The  general  health,  especially  an 
accompanying  anemia,  or  any  indication  of  scrofulosis,  should  be 
given  prompt  treatment.  Locally,  mild,  antiseptic  alkaline  douches, 
or  an  oily  solution,  or  cotton  tampons  saturated  with  a  3  per  cent, 
hydrogen  peroxide  are  useful  in  removing  the  crusts  and  stimulating 
secretion.  Gentle  massage  of  the  mucous  membrane  with  a  cotton- 
tipped  probe  seems  beneficial. 

PURULENT    RHINITIS. 

A  short  time  after  birth  a  thick,  yellowish  pus  is  occasionally  seen 
exuding  from  both  nostrils  of  a  baby  whose  mother  has  suffered  from 
a  purulent  vaginal  discharge  at  the  time  of  delivery.  Such  an  infec- 
tion, usually  limited  to  the  anterior  nasal  cavities,  can  be  avoided 
by  proper  care.  Once  it  has  occurred,  hydrogen  peroxide,  15  vol., 
or  a  mild  alkaline  antiseptic,  should  be  used  for  thorough  cleansing 
followed  by  an  astringent  lotion  applied  by  atomizer  or  swab. 

EPISTAXIS. 

Nose-bleeding  is  rare  in  very  young  infants  except  in  cases  of  sepsis 
or  of  syphilis.  During  childhood,  however,  epistaxis  is  quite  common, 
apparently  more  so  in  boys,  though  girls  are  likely  to  suffer  from  it 
at  puberty.  The  cause  is  not  always  obvious,  but  local  and  general 
factors  together  with  mere  delicacy  of  the  tissues  are  responsible  for 
most  of  the  cases.  Local  causes  include  inflammatory  changes,  the 
presence  of  foreign  bodies,  tuberculosis,  syphilis,  erosions  of  the  septal 
mucous  membrane,  and,  more  especially,  trauma  from  falls,  blows, 
or  picking  of  the  nose.  Epistaxis  may  occur  in  general  infections, 
such   as  typhoid   fever,    malaria,   measles,    influenza,    scarlet   fever, 


396  DISEASES  OF   THE  RESPIRATORY   TRACT 

whooping-coiigli,  and  nasal  diphtheria;  in  diseases  of  the  ])loud,  sucli 
as  hemophiUa,  grave  forms  of  anemia,  pm-pura,  and  scur\  y;  and  in 
conditions  that  produce  passive  congestion,  stich  as  vahular  heart 
affections,  Briglit's  disease,  adenoids,  croupous  pneumonia.  Mental 
or  physical  excitement,  or  the  slightest  injury  to  the  mucous  mem- 
brane, may  also  excite  epistaxis.  It  usually  proceeds  from  a  vessel 
in  the  anterior  part  of  the  septum,  but  occasionally  the  lesion  is  near 
the  posterior  nares.  The  blood  then  trickles  down  the  throat,  and 
may  be  either  coughed  up,  arousing  a  suspicion  of  hemoptysis,  or  it 
may  pass  on  into  the  stomach  and  be  vomited  up,  or  discharged  through 
the  rectum. 

Treatment. — Any  restriction  around  the  neck  should  at  once  be 
loosened.  Except  in  case  of  an  underlying  constitutional  derange- 
ment the  nasal  hemorrhage  will  often  stop  spontaneously  without 
treatment.  However,  cold  applications  over  the  nose,  the  forehead, 
or  the  nape  of  the  neck  can  do  no  harm;  while  more  efficient  treat- 
ment consists  of  outside  pressure,  digital  compression  of  the  facial 
artery,  the  introduction  of  dry  cotton  compresses  to  the  bleeding 
point,  or  the  application  of  collodion  to  the  bleeding  area.  Should  any 
of  these,  or  a  simple  astringent — a  5  per.  cent,  solution  of  zinc  and 
copper  sulphate  and  lead  acetate — not  suffice,  a  solution  of  adrenalin, 
1  to  10,000,  injected  with  a  soft-rubber  syringe,  or  applied  on  gauze 
strips  over  the  bleeding  point  after  the  removal  of  the  blood-clots, 
will  prove  effective.  For  the  permanent  relief  of  ulcers  or  erosions, 
usually  found  upon  the  anterior  part  of  the  septum,  the  parts  should 
be  thoroughly  cleansed  and  dried,  and  touched  once  or  twice  with  a 
50  per  cent,  silver  nitrate  solution,  or  a  15  per  cent,  solution  of  chromic 
acid.  All  other  means  failing,  the  anterior  and  posterior  nares  may  be 
packed  with  cotton,  either  plain  or  medicated,  with  1  to  1000  adrenalin, 
hydrogen  peroxide  full  strength,  or  8  per  cent,  antipyrin.  This  pack- 
ing should  be  applied  with  a  moderate  degree  of  firmness  but  should 
not  be  allowed  to  remain  in  longer  than  twenty-four  to  forty-eight 
hours  in  order  to  prevent  a  possible  devitalization  of  the  mucous 
membrane.  Tincture  of  ergot  and  calcium  lactate  may  be  given  but 
they  are  usually  not  very  efficacious. 

ADENOIDS. 

Childhood,  especially  between  the  fourth  and  eighth  years,  is  charac- 
terized by  a  peculiar  liability  to  excessive  development  of  lymphoid 
tissue,  chiefly  at  the  upper  crossing  of  the  respiratory  and  alimentary 
passages.  There  it  forms  the  so-called  "ring  of  Waldeyer,"  which  in 
as  many  as  75  per  cent,  of  all  children  who  live  in  moist  climates  or 
near  the  seashore  is  prone  to  increase  to  tumor-like  formations  in 
three  places — the  pharyngeal  and  the  two  faucial  tonsils.  The  fourth 
or  lingual  tonsil  does  not,  as  a  rule,  develop  before  puberty.  The 
adenoid,  also  called  Luschka's  or  the  pharyngeal  tonsiU  is  a  reticular 
structure  filled  with  lymph  cells   rich  in   bloodvessels,  covered   by 


ADENOIDS  397 

several  layers  of  columnar  epithelium,  and  differing  from  the  faucial 
tonsils  by  the  absence  of  follicles.  It  may  be  enlarged  at  any  age, 
even  in  nurslings,  especially  in  idiots;  it  is  soft  and  friable  in  infants, 
and  hard  or  fibrous  in  older  children  and  adults.  While  the  impor- 
tance of  this  diseased  condition  in  children  is  generally  recognized, 
it  does  not  seem  to  be  sufficiently  appreciated  in  infants,  at  least  so 
far  as  efficient  treatment  is  concerned.  In  some  instances,  no  doubt, 
it  is  not  merely  a  local  condition,  but  coexists  with  congenital  syphilis 
or  a  tuberculous  constitution  and  gives  rise  to  symptoms  similar  to 
those  of  syphilitic  coryza;  in  fact,  enlarged  adenoid  gro\\i:h  is,  perhaps, 
the  chief  cause  of  chronic  snuffles. 

It  is  somewhat  astonishing  to  find  that  a  purely  local  condition 
may  produce  so  many  symptoms;  their  severity,  of  course,  depends 
largely  upon  the  size  of  the  adenoid  and  the  presence  or  absence  of 
complicating  inflammatory  processes.  That  these  symptoms  need 
not  necessarily  be  present  in  each  individual  case,  and  that  the  clinical 
picture  of  adenoids  in  a  child  of  six  to  eight  years  differs  considerably 
from  that  of  the  baby,  is  self-evident.  It  may  not  be  superfluous, 
however,  to  point  out  the  fallacy  of  believing  an  infant  has  no  adenoids 
because  it  keeps  its  mouth  closed.  ■  If  we  bear  in  mind  that  at  birth 
the  posterior  choana  are  just  large  enough  to  admit  a  medium-sized 
male  catheter,  a;nd  that  the  nasopharynx  is  very  shallow  indeed,  i 
to  \  of  an  inch,  we  can  readily  see  how  even  an  apparently  small 
adenoid  growth  may  considerably  constrict  or  practically  obstruct 
the  nasal  passages.  Such  interference  with  normal  breathing  leads 
to  all  forms  of  disturbances,  already  discussed  under  the  subject  of 
rhinitis,  and  gives  rise  to  chronic  snuffles,  often  to  mouth-breathing, 
especially  at  night,  and  its  sequelse — difficulty  in  feeding,  dryness  of 
the  mouth,  the  habit  of  snoring,  so  distorting  to  the  features,  and  a 
constant  tendency  to  cold  in  the  head.  Sleep  is  interrupted  and  unre- 
freshing  because  the  little  one  continually  tosses  about  seeking  to 
find  a  position  in  which  he  may  be  able  to  breathe  more  freely,  and 
because  an  irritating  cough  usually  appears  upon  lying  down.  Attacks 
of  pavor  nocturnus  are  common;  excited,  no  doubt,  by  the  respiratory 
difficulty.  Anyone  who  has  been  compelled  to  sleep  for  a  night  with 
his  mouth  open  does  not  easily  forget  the  feeling  of  exhaustion,  the 
bad  taste,  and  the  want  of  appetite  experienced  on  awakening,  and 
will  readily  understand  why  such  children  have  no  relish  for  breakfast. 
Unable  to  masticate  for  any  greater  length  of  time  than  the  period 
during  which  they  can  hold  their  breath,  they  eat  only  enough  to 
satisfy  the  acute  pangs  of  hunger  and  naturally  bolt  their  food; 
through  impeded  respiration  they  inhale  an  amount  of  oxygen  quite 
insufficient  for  intensive  metabolism,  and  they  get  their  sleep  only 
by  snatches.  It  is  not  -astonishing  then  that  the  general  nutrition 
suffers,  with  a  consequent  reduction  in  the  power  of  resistance.  This, 
in  addition  to  a  more  or  less  pronounced  catarrh  of  the  nose,  the  naso- 
pharynx, the  tonsils,  and  the  Eustachian  tubes,  accounts  for  the 
increased  liability  of  these  children  to  all  forms  of  tonsillitis,  to  rheu- 


398  DISEASES  OF  THE  RESPIRATORY   TRACT 

matism,  tuberculosis,  scarlet  fever,  diphtheria,  measles,  etc.,  and  the 
greater  severity  of  their  s^Ttiptoms  if  attacked  by  any  of  these  diseases. 

The  speech  is  peculiarly  thick.  In  exceptional  cases  stuttering  and 
stammering  are  reported  to  have  been  cured  by  adenectomy.  The 
hearing  also  is  often  impaired;  for  the  narrowing  or  obstruction  of 
the  Eustachian  tube  interferes  with  the  proper  ventilation  of  the 
middle  ear,  and  thus  causes  retraction  of  the  drum-head.  Other 
disorders  observed  are  those  of  taste  and  smell,  irregular  dental  devel- 
opment, a  high  palatal  arch,  flat  chest,  diminished  lung  expansion, 
and,  where  there  is  a  tendency  to  rickets,  deformities  of  the  bony 
thorax.  While  there  is  as  yet  no  positive  proof  that  adenoids  cause 
asthma,  chorea,  or  epilepsy,  except  in  the  presence  of  inherited  neuro- 
pathic tendencies,  yet  it  is  a  fact  that  enuresis  has  in  some  cases  been 
cured  by  the  removal  of  large  adenoid  vegetations.  J.  R.  Clemens 
has  recently  pointed  out  that  children  with  h^'pe^t^ophied  tonsils  and 
adenoids  show  excessive  general  perspiration  while  asleep,  but  not 
during  their  waking  hours.  This  abnormal  sweating  might  well  be 
mistaken  for  an  early  symptom  of  rickets  were  it  not  that  it  disap- 
pears after  surgical  removal  of  the  excessive  h^^lphatic  gro^^'th. 

Aprosexia,  indifference  to  and  diminished  capacity  for  mental 
work,  especially  noticeable  in  school  children  with  adenoid  disease, 
is  no  doubt  partly  due  to  defective  hearing  which  arises  from  the 
rarefaction  of  the  air  in  the  middle  ear;  there  is,  however,  a  probability 
that  enlarged  adenoids  pressing  upon  the  posterior  and  lateral  walls 
of  the  nasal  pharynx  mterfere  with  the  return  flow  of  lymph  or  blood 
from  the  brain,  and  cause  mental  disturbance  by  reflex  action.  Chil- 
dren with  enlarged  adenoids  often  run  a  slight  temperature  for  days 
at  a  time,  and,  as  already  stated,  a  stubborn  mucopurulent  rhinitis 
is  a  common  complaint  in  such  cases.  The  discharge  becomes  more 
or  less  blocked  up  m  the  nose  forming  a  favorable  nidus  for  bacteria, 
and  the  resulting  inflammation  manifests  itself  by  enlargement  of 
the  cervical  lymph  nodes  and  glands.  The  infection  may  reach  the 
middle  ear  tlirough  the  Eustachian  tube  and  produce  an  otitis  media; 
it  may  also  spread  do^Aaiward  and  involve  the  pharynx,  the  larynx, 
the  bronchi,  and  the  lungs.  A  tenacious  secretion  collecting  in  the 
phar\Tix  may  be  the  cause  of  a  spasmodic  cough,  retching,  or  vomit- 
mg,  and  may  simulate  either  bronchitis  or  the  early  stage  of  whooping- 
cough.  INIany  a  long-standing  case  of  so-called  bronchitis  disappears 
as  if  by  magic  on  the  siugical  removal  of  previously  unsuspected 
adenoids. 

Treatment. — ^The  lymphoid  tissue  is  most  labile  and,  in  mild  cases, 
the  enlargement  may  possibly  disappear  under  judicious  topical 
applications  of  iodin  and  glycerin  combmed  with  treatment  of  the 
coexisting  rhmitis,  respiratory  gymnastics,  and  last,  but  not  least, 
a  rational  diet  appropriate  to  the  age  and  the  digestive  capacity  of 
the  patient.  Large  adenoids,  however,  which  cause  pronounced  symp- 
toms, cannot  be  thus  melted  away,  and  no  time  should  be  lost  in  resort- ' 
ing  to  the  necessary  sm-gical  measures. 


ADENOIDS  399 

When  should  an  operation  be  undertaken  ?  As  soon  as  the  condition 
causes  any  noteworthy  symptoms.  With  an  infant  it  may  be  wise 
to  wait  until  the  fifth  or  sixth  month  of  life.  To  delay  longer  simply 
because  the  adenoid  vegetations  may  recur  does  not  seem  justifiable, 
especially  in  view  of  their  deleterious  influence  upon  development 
during  this  period  of  very  active  grov/th.  No  definite  rule,  however, 
can  be  laid  down  for  cases  in  which  the  hypertrophy  is  only  slight  and 
the  symptoms  apparently  absent;  we  say  apparently,  because  close 
observation  often  reveals  manifestations  which  had  escaped  attention 
before. 

If  spring  or  early  summer  can  be  chosen  for  the  operation,  the  patient 
will  have  more  time  in  which  to  recuperate  before  the  onset  of  cold 
weather.  The  long-standing  cases  operated  upon  late  in  the  fall 
may  again  exhibit  the  old  susceptibility  to  colds  during  the  winter 
that  follows.  While  an  acute  inflammation,  of  course,  necessitates 
a  postponement  of  operative  interference,  this  need  not  be  delayed 
on  account  of  a  slight  rise  in  temperature — 100°  to  101°  F. — if  it  is 
due  to  the  presence  of  the  adenoid  itself.  In  fact,  this  temperature 
usually  disappears  after  the  operation.  Perhaps  no  operation  is  so 
often  inefficiently  done.  Whenever  possible,  it  should  be  left  to  the 
skilled  hands  of  the  specialist. 

As  a  rule,  after  two  years  of  age,  the  hyperplasia  involves  all  the 
tonsils,  pharyngeal  as  well  as  faucial;  these  should,  therefore,  not  be 
treated  as  separate  conditions.  About  75  per  cent,  of  all  children  above 
two  years  of  age  that  have  enlarged  adenoids  also  have  enlarged  tonsils. 
The  essential  point  is  complete  extirpation,  though  the  details  of  the 
procedure  itself  may  vary. 

Since  infants  and  weakly  children  cannot  well  endure  hemorrhage, 
and  since  chronic  cases  are  liable  to  bleed  profusely,  some  practitioners 
give  calcium  lactate  or  chloride  in  10-grain  doses  for  two  days  prior 
to  operation,  the  last  dose  being  given  on  the  morning  of  the  operation. 
It  is  a  safe  principle  to  give  a  cathartic  the  night  before  and,  of  course, 
to  withhold  all  food  on  the  day  of  the  operation,  which  should  be 
performed  in  the  early  morning  if  possible.  Infants  under  one  year 
of  age  require  no  anesthetic  for  adenectomy.  There  is  very  little 
shock,  and  the  whole  procedure  is  over  before  the  babe  has  had  time 
to  be  seriously  frightened.  An  assistant,  holding  the  little  patient 
with  its  arms  alongside  the  body  securely  wrapped  in  a  sheet,  presses 
his  right  hand  against  its  arm  and  his  left  hand  against  its  forehead 
in  such  a  way  as  to  incline  the  head  against  his  left  shoulder.  Per- 
haps a  better  plan  is  to  have  a  nurse  seated  with  the  child  on  her 
lap,  with  its  arms  crossed  and  firmly  held.  An  assistant  standing  back 
of  the  chair  steadies  the  infant's  head  between  his  hands  and  at  the 
same  time  keeps  the  mouth  gag  in  place.  The  operator  then  presses 
down  the  tongue,  passes  the  chosen  instrument  (a  Gottstein  or  a 
Kirstein  curette,  or  a  Shutz  adenectome)  behind  the  soft  palate, 
brings  the  blade  forward  as  far  as  possible,  and  then,  by  making  a 
stroke  at  first  backward  and  then  downward,  removes  the  adenoid 


400  DISEASES  OF   THE  RESPIRATORY   TRACT 

in  one  piece.  Any  remaining  particles  can  be  quickly  cleared  out 
with  the  forceps.  The  patient's  head  is  then  held  forward  over  a 
basin  during  the  profuse  bleeding  which  usually  follows  but  which 
lasts  only  a  few  minutes.  If  the  hemorrhage  is  severe,  it  can  easily 
be  checked  by  hot  or  cold  water  locally  applied,  or  by  any  form  of 
cold  application  to  the  face.  The  child  is  put  to  bed  on  its  side  with- 
out a  pillow,  and  should  be  carefully  watched  for  one  or  two  nights 
by  a  nurse,  with  instructions  to  use  a  1  to  5000  adrenalin  chloride  solu- 
tion as  a  spray  in  case  of  secondary  hemorrhage. 


DISEASES   OF   THE   LARYNX. 

ACUTE   LARYNGITIS    (FALSE    CROUP— SPASMODIC    CROUP). 

Acute  laryngitis,  an  inflammation  of  the  laryngeal  mucous  mem- 
brane, is  also  popularh'  kno^Mi  as  false  croup,  or  spasmodic  croup, 
because  in  young  children  of  a  certain  predisposition  it  is  often  asso- 
ciated with  spasm  of  the  glottis  which  gives  rise  to  alarming  symptoms. 
When  associated  with  the  acute  infectious  diseases,  especially  measles, 
acute  lar>'ngitis  may  become  very  serious.  The  occurrence  of  false 
croup  with  influenza,  whooping-cough,  and  scarlet  fever,  is  discussed 
under  these  respective  headings.  Acute  laryngitis  proper  is  nearly 
always  of  microbic  origin.  While  it  may  appear  as  a  primary  disease, 
it  is  usually  secondary  to  an  infection  spreadmg  do\\niward  from  the 
upper  respiratory  passages,  such  as  rhinitis,  tonsillitis,  or  catarrh 
of  the  nasal  pharynx;  m  rare  instances  the  pathological  process  may 
extend  upward  from  the  bronchi  and  the  trachea.  It  is  a  well-known 
fact  that  bacteria  capable  of  producing  inflammation  are  found  on 
the  normal  mucous  membrane,  which  has  the  power  to  destroy  them. 
Their  pathogenicity"  may  be  due  either  to  an  enormous  increase  in 
numbers,  or  to  a  lowered  local  resistance,  the  result  of  congestion 
from  one  cause  or  another,  or  to  an  impaired  general  condition  due  to 
some  chronic  ailment.  Children  under  six  years  of  age  suffering  from 
rickets,  anemia,  malnutrition,  chronically  enlarged  tonsils  and 
adenoids,  or  those  havmg  an  acquired  or  an  inherited  spasmophilia, 
are  particularly  liable  to  have  serious  as  well  as  frequent  attacks  of 
laryngitis  associated  with  spasm  of  the  glottis,  one  attack  apparently 
creating  a  tendency  to  another.  In  children  without  this  predisposi- 
tion or  in  those  over  six  years  of  age,  the  disease  is  comparatively  mild 
in  type  and  devoid  of  spasmodic  manifestations. 

Pathology. — The  mucous  membrane  of  the  larynx,  and  often  to  a 
slighter,  degree  that  of  the  trachea  also,  shows  localized  or  general 
h\'peremia  and  a  swelling,  which  seems  limited  to  the  mucosa  in  a 
mild  case,  but  which  may  involve  the  submucosa  in  the  more  severe 
one.    There  is,  however,  very  little  tendency  to  edema  in  children  as 


ACUTE  LARYNGITIS  401 

compared  with  adults.  The  initial  dryness  is  soon  followed  by  an 
increased  secretion  of  mucus  which,  clinging  to  the  swollen  mucosa, 
still  further  narrows  the  lumen  of  the  windpipe,  and  interferes  with  the 
free  passage  of  air.  This  at  times  produces  a  marked  stenosis  which 
may  become  almost  complete,  causing  a  spasm  of  the  laryngeal 
muscles,  especially  of  the  adductors. 

Symptoms. — In  older  children  the  ordinary  case  lasts  from  four  to 
ten  days.  It  is  commonly  preceded  by  nasal  or  pharyngeal  catarrh, 
or  it  may  be  associated  with  influenza,  measles,  or  typhoid.  The 
clinical  picture  of  simple  infantile  laryngitis  closely  resembles  the 
adult  type,  except  that  the  cough  is  more  croupy  and  the  dyspnea 
more  marked.  All  the  symptoms — slight  fever,  cough,  dyspnea,  and 
hoarseness — become  more  pronounced  at  night.  Usually  there  is 
pain  and  tenderness  over  the  larynx.  Alarming  symptoms  are  seen 
principally  in  infants  and  young  children,  for  even  a  moderate  swelling 
of  the  laryngeal  mucous  membrane  in  a  very  young  child  interferes 
with  inspiration  and  may  readily  cause  an  obstruction,  especially  if 
there  is  a  tendency  to  spasms,  so  usual  in  infants.  In  mild  cases  the 
hoarseness,  the  cough,  and  a  high  temperature,  100°  to  103°  F., 
may  continue  for  a 'few  days,  and  then  pass  off  without  more  severe 
manifestations,  but  other  and  more  alarming  symptoms  frequently 
make  their  appearance.  After  having  played  around  all  day  apparently 
well  except,  perhaps,  for  a  slight  coryza,  the  child  toward  evening 
develops  a  slight  hoarseness  and  a  barking  cough,  which  so  increase 
in  severity  and  frequency  that  sleep  becomes  restless.  There  is  no 
evidence  of  serious  illness,  the  temperature  rise  being  only  slightly 
above  the  normal,  but  respiration  gradually  becomes  increasingly 
difficult,  until  suddenly  the  child  awakens  terrified,  sits  up,  apparently 
suffocating,  and  struggles  for  breath.  The  alse  nasi  vibrate  rapidly, 
all  the  accessory  respiratory  muscles  are  brought  into  play,  the  lips 
and  the  finger  tips  become  livid,  and  the  labored  breathing  with  its 
loud  inspiratory  stridor  is  only  interrupted  by  a  loud,  ringing,  metallic 
cough,  which  is  sometimes  hoarse  and  harsh.  The  distress  may  last 
from  a  few  minutes  to  one-half  or  a  full  hour,  often  longer,  but  in  a 
somewhat  milder  form,  until  finally  the  little  patient  falls  back 
exhausted  to  continue  his  interrupted  sleep.  When  he  awakes  the 
next  morning  the  dyspnea  has  completely  disappeared,  and  he  is 
apparently  as  bright  and  well  as  ever  except  for  a  hoarse  voice  and 
some  cough.  However,  unless  adequate  treatment  is  given,  the  cough, 
the  hoarseness,  and  the  dyspnea  are  liable  to  return  at  nightfall  and 
to  culminate  in  a  second  attack,  perhaps  even  more  severe  than  the 
first  one.  Usually  these  symptoms  do  not  recur  more  than  three 
nights  in  succession,  but  after  exposure  or  other  indiscretions  some 
children  suffer  from  slight  laryngeal  spasms  every  few  weeks  during 
the  cold  season. 

Treatment. — Even  mild  cases  must  be  treated  with  care  on  account 
of  the  possible  development  of  spasms  or  of  edema.  The  child  should 
be  purged  with  calomel  given  in  divided  doses,  and  should  be  put  to 
26 


402  •       DISEASES  OF   THE  RESPIRATORY   TRACT 

bed  in  a  warm  (70°  F.),  well-ventilated  room.  Inhalations  of  steam, 
plain,  or  medicated  with  tincture  of  benzoin  comp.,  oil  of  eucalyptus 
or  creosote,  repeated  in  severe  cases  every  two  hours  for  fifteen 
minutes,  are  very  soothing  to  the  inflamed  mucous  membrane.  If 
the  adjacent  structures,  the  faucial  or  lingual  tonsils,  or  the  naso- 
pharynx are  inflamed  they  must  be  energetically  treated.  Hot  drinks, 
lemonade,  but  bette/  still  milk  with  lime-water,  help  to  start  the 
secretion;  when  the  latter  grows  profuse,  expectorants  are  indicated. 

A  teaspoonful  of  the  syrup  or  the  wine  of  ipecac  relieves  the  spasm 
and  the  cough  for  a  time  by  causing  vomiting  of  the  accumulated 
secretions,  but  such  medication  cannot  be  advised  for  weakened  chil- 
dren. In  some  cases  antipyrin  in  small  doses — 1  grain  for  a  child 
of  two  years — every  two  hours,  may  be  necessary  for  relieving  the 
spasm,  and  syrup  of  ipecac  and  squills,  of  each  5  drops,  for  soothing 
the  irritating  cough,  while  some  exceptional  cases  may  require  heroin, 
To  grain,  or  Dover's  powders  in  small  doses. 

When  in  connection  with  the  dyspnea,  the  stridor,  and  the  respira- 
tory recession,  there  is  marked  frequency  of  respiration  with  extreme 
lividity  or  pallor  and  prostration,  it  may  become  necessary,  especially 
in  a  very  young  child,  to  perform  intubation  of  even  tracheotomy. 
It  goes  without  saying  that  a  good  prophylactic  dose  of  diphtheria 
antitoxin  should  be  given  in  every  doubtful  case.  During  convales- 
cence little  treatment  will  be  required  beyond  the  use  of  the  syrup  of 
hydriodic  acid  and  ferrous  oxide  as  a  tonic,  and  protecting  the  child 
against  exposure. 

Prophylaxis. — Proper  clothing,  an  out-of-door  life,  a  daily  cold  sponge 
followed  by  brisk  friction,  a  simple  nourishing  diet  supplemented  by 
tonics — malt  extract  and  cod-liver  oil — these  together  with  an  annual 
stay  at  the  seashore  or  the  mountains,  when  possible,  will  go  far  to 
prevent  the  recurrence  of  croup;  the  predisposed  child,  however, 
must  not  be  subjected  to  extreme  changes  of  temperature,  or  to  expo- 
sure to  wet,  and  should  be  kept  fpom  contact  with  persons  suft'ering 
from  colds. 


EDEMA  OF  THE  LARYNX  (GLQTTIS)  AND  THE  SUB- 
MUCOUS MEMBRANE. 

These  conditions,  both  of  them  rare,  may  represent  either  a  serous 
infiltration  or  an  inflammatory  edema  of  the  larynx. 

Serous  Infiltration. — A  true  infiltration  of  the  submucous  cellular 
tissues  of  the  larynx  occasionally  occurs  in  chronic  nephritis;  in  fact 
it  may  be  one  of  the  earliest  symptoms  of  the  disease.  Other  etio- 
logical factors  may  be  glands  or  tumors  which  interfere  with  the 
normal  laryngeal  circulation,  cardiac  insufficiency,  and  local  irritation, 
such  as  is  produced  by  inhaling  hot  or  irritating  vapors,  and  by  acci- 
dental swallowing  of  corrosive  liquids.  In  rare  cases,  the  adminis- 
tration of  potassium  iodide  has  been  known  to  produce  a  sudden  edema, 
which  disappeared  readily  when  the  drug  was  discontinued. 


EDEMA  OF   THE  LARYNX  403 

Inflammatory  Edema. — Inflammatory  edema,  the  result  of  a  local 
inflammatory  process,  is  more  common.  This  is  a  true  submucous 
laryngitis,  which  may  be  caused  by  direct  infection,  by  trauma  of 
the  mucous  membrane,  by  ulcers,  impacted  foreign  bodies,  or  by  an 
infection  spreading  from  the  surrounding  tissues;  it  also  occurs  as  a 
rare  complication  in  syphilis,  typhoid  fever,  smallpox,  chicken-pox, 
scarlet  fever,  and  diphtheria.  The  edema  usually  affects  the  epiglottis 
and  the  aryepiglottic  folds,  but  it  rarely  attacks  the  vocal  cords  and 
interarytenoid  folds;  when  associated  with  constitutional  diseases, 
the  swelling  is  apt  to  be  bilateral. 

Symptoms. — While  expiration  may  be  quite  easy,  inspiratory  dysp- 
nea is  the  most  striking  symptom  of  edema  of  the  glottis.  When 
the  aryepiglottic  folds  are  chiefly  involved,  the  laryngeal  orifice  may 
become  practically  closed,  producing  most  alarming  dyspnea  and 
signs  of  suffocation.  Edema  of  the  other  parts  of  the  larynx  is  not 
likely  to  embarrass  the  respiration  to  the  same  extent.  The  sudden- 
ness of  the  onset  depends  greatly  upon  the  exciting  cause,  but,  as  a 
rule,  the  distressing  symptoms  develop  with  great  rapidity  and  may 
prove  fatal  within  a  few  hours.  To  this  clinical  picture  may  be  added 
pain,  cough,  hoarseness,  and  dysphagia,  if  the  condition  is  of  inflam- 
matory origin;  and,  naturally,  also  all  the  symptoms  of  a  coexisting 
primary  disease. 

Diagnosis. — The  examining  finger,  duly  protected,  detects  a  swell- 
ing around  the  base  of  the  tongue  and  a  more  or  less  pronounced 
tumefaction  at  either  side  of  it.  When  the  tongue  is  drawn  forward 
during  inspection,  or,  better,  when  the  laryngeal  mirror  is  introduced, 
tumors  are  seen  close  together  near  the  root  of  the  tongue,  their  whitish 
color  indicating  a  serous  origin,  or,  if  reddish,  an  inflammatory  origin; 
in  the  latter  case  there  is  also  tenderness  over  the  larynx  and  the 
trachea.  Careful  examination  of  the  heart  and  of  the  urine  should 
never  be  omitted  unless  the  history  and  the  accompanying  signs  and 
symptoms  leave  no  doubt  as  to  the  true  cause  of  the  condition. 

Prognosis. — Prognosis  depends  upon  the  patient's  general  condition, 
the  underlying  cause,  and  the  promptness  with  w^hich  the  dyspnea 
can  be  relieved  by  medical  means,  or,  in  severe  cases,  by  surgical 
measures. 

Treatment. — While  the  ultimate  success  depends  upon  ascertaining 
the  etiological  factor  and  treating  it  effectively,  local  treatment  at  the 
time  of  the  attack  is  of  paramount  importance.  When  there  is  no 
danger  of  suffocation,  cold  compresses,  externally,  and  ice  by  mouth 
are  useful.  Topical  applications  of  adrenalin  may  also  be  tried.  In 
the  inflammatory  form  leeches  over  the  larynx,  multiple  punctures 
of  the  edematous  tissues,  deep  incision  where  an  abscess  is  suspected, 
each  has  its  advocates.  When  the  dyspnea  is  extreme,  Heubner 
recommends  intubation,  followed,  if  necessary,  by  tracheotomy  and 
subsequent  local  treatment.  At  all  eVents,  one  should  be  prepared 
to  perform  tracheotomy  if  suffocation  seems  imminent. 


■104  DISEASES  OF   THE  RESPIRATORY   TRACT 

LARYNGISMUS   STRIDULUS    (CHILD-CROWING). 

This  disease,  peculiar  to  infancy  and  comparatively  rare  except  in 
foundling  institutions,  is  no  doubt  a  neurosis,  causing  an  incoordina- 
tion of  the  laryngeal  muscles. 

Etiology. — The  majority  of  cases  occur  chiefly  in  male  infants  from 
six  to  eighteen  months  of  age,  and  usually  during  the  winter  months, 
when  babies  are  more  or  less  closely  confined  to  overheated  rooms. 
In  children  suffering  from  rickets,  tetany,  hereditary  syphilis,  or 
other  diseases  that  produce  profomid  malnutrition  and  excessive 
excitability  of  the  nervous  system,  attacks  of  laryngismus  stridulus 
are  easily  mduced  by  nervous  excitement,  or  by  almost  any  kind  of 
peripheral  stimulation.  A  breath  of  cold  air  blowing  across  the  sen- 
sitive skin  of  such  a  delicate  neurotic  child,  or  the  reflex  action  of 
certain  nasal  conditions,  or  enlarged  cervical  or  bronchial  glands,  the 
acute  inflammation  of  adenoids  and  tonsils,  postnasal  dropping  of 
mucus  into  the  larynx,  a  tickling  of  the  tliroat,  or  some  gastric  dis- 
tiubance,  as  well  as  fits  of  temper,  of  fright,  and  of  crymg  are  sufficient 
to  cause  a  spasm  of  the  respiratory  muscles,  especially  of  the  laryngeal 
abductors,  resultmg  m  sudden  closure  of  the  glottis  and  the  partial 
or  complete  shutting  off  of  ah  from  the  lungs. 

Symptoms. — While  the  affection  when  mild  may  pass  unnoticed  in 
the  beginning,  on  the  other  hand,  the  very  first  attack  may  awaken 
the  child  from  its  sleep  and  startle  the  family  by  its  suddemiess  and 
severity,  the  latter  depending  almost  entirely  upon  the  degree  of 
spasm.  Just  before  the  glottis  closes  the  inrushing  ah  makes  a  peculiar 
noise  which  frightens  the  child  and  causes  it  to  struggle  for  breath; 
its  chest  remauis  fixed  and  its  body  stiffens,  while  the  epigastrium 
bulges  and  feels  as  hard  as  a  board.  Respiration  ceases,  although  the 
diaphragm  appears  to  move  convulsively,  the  face  tm-ns  first  pale, 
then  livid.  With  its  head  throT^^l  back  and  its  eyeballs  rollmg,  the 
life  of  the  little  patient  seems  to  be  m  immment  danger.  After  some 
anxious  moments,  a  sudden  deep  insphation,  usually  but  not  always 
accompanied  by  a  crowing  sound,  shows  that  the  spasm  is  broken, 
and  the  danger  past.  The  child  breathes  rapidly,  its  terror  dissolves 
in  tears,  and  after  fretting  and  crying  a  little,  it  finally  falls  asleep, 
and  on  awakmg  seems  as  well  as  ever. 

Although  these  attacks  usually  come  on  at  night,  and  awaken  the 
child  out  of  a  deep  sleep,  they  may  appear  at  any  time,  and  may  be 
repeated  two  or  three  times  a  day;  in  severe  cases  even  as  many  as 
twelve  attacks  have  occurred  m  twenty-four  hoiu-s.  The  mild 
seizures  pass  off  hi  ten  to  twenty-five  seconds,  leaving  apparently 
no  ill  effects;  but  the  more  severe  ones  may  be  followed  by  gen- 
eral convulsions,  loss  of  consciousness,  and  may  even  terminate 
fatally. 

Carpopedal  spasm  is  observed  in  about  50  per  cent,  of  all  cases,  and, 
when  present,  becomes  mtensified  durmg  the  attack.  Laryngismus 
stridulus  may  last  for  a  few  days  or  for  several  months,  recovery  being 


LARYNGISMUS  STRIDULUS  405 

heralded  by  a  gradual  decline  in  the  severity  and  the  number  of  the 
paroxysms  until  they  finally  cease  entirely. 

Diagnosis. — The  differential  diagnosis  is  easy  if  the  clinical  picture 
and  the  history  are  kept  in  mind,  especially  the  fact  that  the  patient 
is  comfortable  during  the  intervals.  In  laryngismus  stridulus  a  period 
of  apnea  precedes  the  crowmg  insphation,  while  the  whoop  of  pertussis 
immediately  follows  a  series  of  short  expirations.  Catarrhal  laryngeal 
spasm  is  always  associated  with  symptoms  of  acute  laryngitis;  con- 
genital laryngeal  stridor  dates  from  birth;  in  diphtheritic  croup  the 
dyspnea  is  lasting  and  increases  in  severity;  spells  of  so-called  "hold- 
ing of  the  breath"  are  usually  brought  on  by  anger. 

Prognosis. — The  prognosis  is  good  when  the  underlying  cause  can 
be  treated  successfully,  and  also  favorable  as  far  as  the  attack  itself 
is  concerned;  although  weak  infants  are  known  to  have  died  from 
asphyxia  or  from  subsequent  convulsions. 

Treatment. — During  an  attack  the  primary  object  is,  of  coinse,  to 
break  the  spasm  and  to  produce  an  inspiration.  For  this  purpose, 
inverting  the  patient  and  lightly  slapping  him  on  the  back  often 
proves  as  effective  as  it  is  simple.  Dashing  cold  water  on  the  face 
and  the  chest,  tickling  the  fauces,  alternate  hot  and  cold  baths  in 
rapid  succession,  a  hot  sponge  over  the  larynx,  or  a  whiff  of  chloroform 
administered  by  a  competent  person,  have  all  been  found  useful; 
But,  if  these  means  should  fail  to  give  prompt  relief,  intubation  or 
tracheotomy  becomes  necessary. 

Following  the  paroxysm  the  child  should  be  kept  under  the  influence 
of  chloral  for  twenty-four  hours,  and  for  a  week  or  two  sodium  bromide 
should  be  given,  5  grains  three  times  a  day  in  cinnamon  water.  Con- 
sidering that  many  of  these  cases  suffer  from  disturbances  of  nutrition, 
antipyrin,  1  grain,  may  be  given  every  four  hom*s  to  a  child  one  year 
old ;  antipyrin  does  not  disturb  the  digestion  as  do  the  bromides,  unless 
the  bromides  are  given  by  rectum.  The  infant  must  be  kept  from  all 
excitement,  such  as  loud  talking,  the  noisy  play  of  other  children,  as  well 
as  the  devoted  attentions  of  relatives  and  friends.  Of  course,  the  under- 
lying malnutrition,  rickets,  tetany,  syphillis,  tuberculosis,  or  the  disease 
of  the  nose  or  throat  should  be  treated  in  the  most  effectual  way. 

Congenital  Laryngeal  Stridor. — This  is  an  inspiratory  stridor 
peculiar  to  infants,  but  of  rare  occurrence,  usually  noticed  very  shortly 
after  birth  and  disappearing  spontaneously  during  the  second  year, 
Hutchinson  calls  the  condition  "a  stammer  of  respiration."  It  may 
be  due  to  incoordination  of  the  laryngeal  muscles  or  it  may  represent 
a  neurosis  like  laryngismus  stridulus.  Some  writers  suggest  a  mal- 
formation of  the  larynx  or,  rather,  a  peculiar  folding  of  the  epiglottis 
upon  itself  along  the  median  Ime  and  a  flabbiness  of  the  false  vocal 
cords,  which  allow  the  larynx  to  fall  upon  itself  on  inspiration,  thus 
producing  a  valve-like  action. 

Etiology. — ^As  regards  the  etiology,  we  know  little  beyond  the  fact 
that  the  affection  is  congenital  and  that  it  may  be  increased  by  excite- 
ment as  well  as  by  exposure  to  cold. 


406  DISEASES  OF   THE  RESPIRATORY   TRACT 

Symptoms. — While  expiration  to  all  appearances  is  easy  and  noise- 
less, an  inspiratory  stridor  in  the  form  of  a  cnrious  slight  crowing 
or  purring  in  the  throat  is  heard.  This  sound  varies  in  intensity  and 
may  at  times  cease  altogether;  it  is  rarely  audible  during  sleep,  but 
is  apt  to  be  louder  when  the  child  becomes  excited.  The  voice  remains 
unaffected,  and,  in  spite  of  a  slight  cyanosis  which  accompanies  the 
dyspnea,  the  child  does  not  seem  uncomfortable.  The  paroxysms  of 
dyspnea  usually  mcrease  in  severity  during  the  first  few  months  of 
life  and  gradually  subside  in  the  course  of  the  second  year. 

Diagnosis. — The  disorder  is  readily  differentiated  from  laryngeal 
spasm  associated  with  enlarged  adenoids,  laryngismus  stridulus,  thymic 
asthma,  papilloma  and  edema  of  the  larynx,  by  its  history,  its  onset 
immediately  after  birth,  by  its  characteristic  respiration  accompanied 
by  inspiratory  dyspnea,  and  by  the  fact  that  the  patient  is  not  uncom- 
fortable and  the  voice  remains  unaffected. 

Prognosis. — Prognosis  is  good  unless  complicated  by  bronchopneu- 
monia. 

Treatment. — The  condition  has  a  tendency  to  disappear  spon- 
taneously, and  therefore  requires  no  special  treatment;  but  the  child 
should  be  protected  from  nervous  excitement  and  undue  exposure, 
especially  to  diseases  of  the  respiratory  tract.  In  infants  these  have 
a  decided  tendency  to  spread  to  the  larynx  and  the  bronchi;  in  such 
cases  every  preparation  for  performing  tracheotomy  or  intubation 
should  be  made  in  time.  Pure  air,  sunshine,  careful  feeding,  and  the 
usual  hygienic  measures  for  improving  the  general  condition  will  help 
to  shorten  the  course  and  to  modify  the  severity  of  the  disease. 

NEW    GROWTHS    OF    THE   LARYNX. 

Laryngeal  tumors  rarely  occur  m  children  and  only  exceptionally 
are  they  malignant.  Of  the  benign  growths,  papillomata  represent 
the  most  common  ^'ariety;  fibromata  and  myxomata  are  too  rare  to 
require  consideration.  Papillomata  are  probably  congenital  in  about 
25  per  cent,  of  all  cases,  the  majority  of  them  making  their  appearance 
from  the  first  to  the  fourth  year,  sometimes  developing  rapidly  after 
laryngeal  catarrh.  Boys  seem  to  be  more  frequently  affected  than 
girls.  The  growths,  usually  situated  on  the  vocal  cords  or  within  them, 
may  be  single  or  multiple,  sessile  or  pedunculated,  and  sometimes  may 
attain  the  size  of  a  large  raspberry. 

Symptoms. — The  symptoms  naturally  depend  to  a  certain  extent 
upon  the  size  and  the  location  of  the  tumor,  but  they  usually  resemble 
those  of  chronic  laryngitis.  A  change  of  voice,  a  gradually  increasing 
hoarseness  and  occasional  paroxysms  of  coughing  are  the  early  mani- 
festations which  may,  indeed,  date  from  birth,  but  which  more  infre- 
quently appear  during  infancy  and  are  progressive  instead  of  passing 
off  as  in  ordinary  laryngitis.  The  mcreasing  size  of  the  growth  even- 
tually causes  a  certain  degree  of  obstruction,  the  breathing  becomes 
somewhat  difficult,  perhaps  at  first  more  noticeable  during  sleep,  but 


FOREIGN  BODIES  IN   THE  LARYNX  407 

later  also  in  the  daytime,  especially  when  the  cliild  exerts  itself  in 
any  way.  Usually  no  pain  is  experienced  on  swallowing  and  thus 
months  may  elapse  before  the  slowly  progressing  symptoms,  accen- 
tuated, perhaps,  by  repeated  severe  paroxysms  of  coughing  or  of 
suffocative  attacks,  compel  serious  attention. 

Diagnosis. — In  all  cases  of  long-standing  stubborn  laryngitis,  a 
papilloma  should  be  suspected,  but  a  positive  diagnosis  can,  of  course, 
only  be  made  by  the  use  of  the  laryngoscope. 

Prognosis. — Papillomata  sometimes  disappear  spontaneously  if  the 
larynx  is  given  absolute  rest  for  a  few  months.  Surgical  removal  is 
followed  by  immediate  and  pronounced  relief,  but  there  is  always  a 
possibility  of  recurrence;  indeed,  removal  seems  to  stimulate  the 
growth  of  subsequent  crops. 

Treatment. — Treatment  should  be  entrusted  to  a  skilful  laryngolo- 
gist,  who,  if  the  child  is  tractable,  may  decide  either  on  the  endolaryn- 
geal  method  of  removal  with  the  forceps  or  wire  snare.  Occasionally 
th.^Totomy  or  laryngofissure  with  curettage  may  be  resorted  to.  The 
latter,  however,  greatly  endangers  the  quality  of  the  voice  and,  aside 
from  the  difficulty  of  anesthetizing  the  patient,  there  is  the  risk  of 
postoperative  bronchial  pneumonia.  To  prevent  recurrence  the 
long-continued  use  of  Fowler's  solution  has  been  recommended  as 
one  of  the  best  prophylactic  measures. 

FOREIGN  BODIES  IN  THE  LARYNX,  THE  TRACHEA,  AND 
THE  BRONCHI. 

Particles  of  food,  buttons,  pins,  tacks,  seeds,  pebbles,  bullets,  and 
coins,  in  fact,  all  objects  which  a  child  playfully  puts  into  its  mouth, 
can,  if  small  enough,  be  aspirated  into  the  larynx  or  the  trachea  during 
an  attempt  at  crying  or  laughing,  or  a  sudden  inspiration  occasioned 
by  an  attack  of  coughing,  hiccoughing,  or  choking.  The  resultant 
symptoms  will  naturally  depend  upon  the  size,  the  shape,  and  the 
nature  of  the  object  swallowed  and  the  age  of  the  child;  for  even  very 
small  bodies  may  cause  dangerous  symptoms  in  the  infant  owing  to 
the  small  size  of  its  larynx.  As  a  violent  fit  of  coughing  and  of  suffoca- 
tive attacks  usually  follows  the  accident,  this  frequently  helps  to 
expel  the  foreign  body  or  to  make  it  slip  along  the  trachea  into  one  of 
the  bronchi,  usually  on  the  right  side,  owing  to  local  anatomical  con- 
ditions. Sharp  objects  like  fish  bones,  pins,  shells,  etc.,  instead  of 
becoming  dislodged  often  become  imbedded  in  the  larynx  and  produce 
edema  or  occlusion  of  the  glottis,  which  may  result  in  sudden  death 
unless  immediate  relief  is  given.  Or  they  may  penetrate  so  deeply 
into  the  soft  tissue  thay  they  cannot  easily  be  seen  or  felt,  so  that 
either  blood-stained  sputum,  a  spasm  of  the  glottis,  severe  inflam- 
mation, edema,  perichondritis,  or  an  erosion  of  the  bloodvessels  may 
result.  The  severe  lesions  finally  may  lead  to  a  certain  degree  of 
permanent  stenosis  owing  to  cicatrices  that  form  during  the  process 
of  healing.  The  object  which  has  passed  down  the  trachea  may  cause 
a  great  variety  of  other  symptoms  besides  the  paroxysmal  cough, 


408  DISEASES  OF   THE  RESPIRATORY   TRACT 

the  bloody  sputum,  and  the  locaHzed  pam  m  the  chest.  A  whole  lung 
or  part  of  it  may  become  atelectatic,  depending  on  the  size  of  the 
bronchus  occluded,  with  absence  of  respiration  and  diminished 
resonance.  Sometimes  the  inspired  body  acts  as  a  valve  and  permits 
only  inspiration,  thus  causmg  a  rapidly  developmg  emphysema  with 
all  its  concomitant  physical  signs.  If  the  foreign  body  is  not  removed 
it  excites  a  local  inflammation  which,  spreading  to  the  surromiding 
lung  tissue,  may  result  in  the  development  of  pulmonary  abscesses. 
These  in  turn  may  produce  a  high  irregular  septic  fever  that  may  end 
fatally  with  symptoms  that  somewhat  resemble  pulmonary  tuberculosis. 

Diagnosis. — The  diagnosis  can  usually  be  made  from  the  history  of 
"something  having  been  swallowed  the  wrong  way,"  the  suddenness 
of  the  attack  and  the  violence  of  the  early  symptoms.  Digital  exam- 
ination is  somewhat  dangerous,  but  Roentgen  rays  are  a  great  help  m 
many  cases.  Older  children  can  be  quieted  down  sufficiently  for  an 
examination  by  the  laryngoscope  or  the  bronchoscope,  but  this  may 
prove  rather  difiicult  with  a  young  child.  It  may  be  mentioned,  in 
passing,  that  a  lateral  pharyngitis  may  be  responsible  for  the  sensa- 
tion of  a  foreign  body  m  the  tliroat.  On  the  other  hand,  a  troublesome 
cough  with  some  physical  signs  of  bronchitis  or  of  pneumonia  in  a 
young  child  that  presents  increased  respiratory  movements  on  one 
side,  and  diminished  vesicular  murmur  on  the  other,  will  suggest  the 
possibility  of  an  obstructed  bronchus. 

Prognosis. — The  prognosis  is  rather  uncertam,  much  dependmg  upon 
the  nature  of  the  foreign  body  and  its  location;  for  even  when  situated 
below  the  lar\TLX  it  is  by  no  means  impossible  for  it  to  be  expelled 
spontaneously.  Suffocation  is  the  most  frequent  cause  of  a  fatal 
termination,  especially  when  the  object  is  large  enough  completely  to 
obstruct  the  lar^^lgeal  opening. 

Treatment. — Nothing  should  be  done  that  may  cause  a  sudden 
insphation ;  emetics  are  therefore  not  advisable ;  nor  should  an  instru- 
ment or  the  finger  be  rashly  introduced  into  the  larynx,  while  care 
should  be  taken  not  to  push  the  obstructmg  body  down  into  the 
trachea.  Inversion  of  the  patient,  in  the  hope  of  thus  assisting 
Nature's  effort  to  expel  the  offending  particles  by  coughing,  may  be 
tried.  Immediate  tracheotomy  may  become  necessary,  but  intubation 
is  contra-indicated.  Urgent  cases  admit  of  no  delay,  and  a  skilled 
laryngologist  should  be  called  immediately  since  only  a  specialist 
should  undertake  to  remove  a  foreign  body  from  the  trachea  or  the 
bronchi. 


DISEASES   OF   THE   BRONCHI. 

ACUTE    BRONCHITIS. 

Acute  bronchitis  is  an  inflammation  of  the  mucous  membrane  of  the 
trachea  and  the  bronchi  with  a  tendency,  more  pronounced  in  infants, 
to  involve  the  small  bronchi  as  well. 


ACUTE  BRONCHITIS  409 

Etiology. — It  is  often  observed  during  the  course  of  infectious 
diseases,  especially  measles,  scarlet  fever,  pertussis,  or  epidemic  grippe, 
but  the  essential  etiological  factor  of  simple  bronchitis  is,  no  doubt, 
an  inflammation  caused  by  the  single  or  combmed  action  of  the  staphy- 
lococcus, pneumococcus,  influenza  bacillus  and  Bacillus  catarrhalis, 
or  by  the  bacilli  of  typhoid  and  of  diphtheria.  Since  the  normal 
mucous  membrane  destroys  the  majority  of  invading  germs,  it  is  to 
be  assumed  that  something  diminishes  this  self-protective  power  and 
thus  makes  it  easy  for  pathogenic  bacteria  to  uivade  the  deeper  regions 
of  the  respiratory  apparatus  and  there  to  multiply.  In  some  chil- 
dren, especially  fat,  flabby,  and  pasty-looking  ones,  there  may  be  an 
individual  predisposition  of  the  mucous  membrane  itself;  this  theory 
would  at  least  explain  why  apparently  the  same  cause  will  produce 
a  simple  catarrh  in  one  child,  and  a  diffuse  bronchitis  or  an  intestinal 
disturbance  in  another  child  of  the  same  family. 

Very  young  children  (between  three  and  six  months  of  age)  show  a 
marked  susceptibility  which,  however,  rapidly  decreases  m  the  fourth 
year.  Lowered  vitality  from  any  cause  naturally  weakens  the  local 
resistance  in  children  even  more  so  than  in  adults;  hence,  mouth- 
breathing,  chronic  nasopharyngeal  affections,  glandular  and  other 
forms  of  tuberculosis,  anemia,  s.yphilis,  and  similar  conditions,  favor 
the  development  of  bronchitis.  Lack  of  hygiene,  uncle anliness,  sun- 
less dwellings,  want  of  care  (constant  dorsal  position),  undue  exposure 
either  during  the  daily  bath  of  the  mfant  or  by  insufficient  clothing, 
not  to  speak  of  bare  legs  during  inclement  weather  (favored  by  a 
barbarous  custom  of  endeavoring  to  "harden"  the  child),  wet  feet, 
raw  winds,  sudden  atmospheric  changes,  are  all  frequently  responsible 
for  bronchial  attacks.  While  it  is  true  that  a  sudden  chilling  of  the 
body  surface  may  be  harmful,  on  the  other  hand  we  can  not  too  strongly 
condemn  the  excessive  anxiety  which,  during  the  cold  months,  keeps 
children  confined  in  close,  overheated,  ill-ventilated  rooms,  in  school 
or  at  home,  and  compels  them  to  breathe  impure,  germ-laden  air. 

Pathology. — Our  concern  here  is  not  with  a  localized  bronchitis 
secondary  to  pulmonary  disease,  but  with  an  aciite  catarrhal  process. 
This  is  usually  bilateral,  rarely  appears  in  patches,  and  primarily 
affects  the  mucous  membrane  of  the  trachea  and  the  bronchi.  The 
mucous  membrane  is  injected  and  swollen,  its  glands  and  its  goblet 
cells  are  markedly  increased  in  number  and  pour  out  an  excess  of 
secretion,  which  soon  changes  from  serous  to  mucopurulent,  and  con- 
tains desquamated  epithelium,  many  bacteria,  and  leukocytes.  In 
acute  attacks  the  lymph  nodes  at  the  root  of  the  lung  are  slightly 
swollen,  the  swelling  being  more  marked  in  protracted  or  reciu"rent 
attacks.  The  mucosa  and  submucosa  are  infiltrated  with  small  round 
cells  and  pathological  bacteria.  The  inflammation  is  limited  to  the 
bronchial  walls.  An  extension  to  the  peribronchial  tissues  would  be 
bronchopneumonia,  as  is  also  the  so-called  capillary  bronchitis  of 
children  which,  postmortem,  shows  changes  m  the  air  vesicles  sur- 
roundmg  the  bronchioles.     In  chronic  bronchitis  the  mucous  mem- 


410  DISEASES  OF   THE  RESPIRATORY   TRACT 

brane  is  thickened  and  of  a  brownish-red  color,  while  a  certain 
amount  of  emphysema,  dilatation  of  the  smaller  bronchi,  and  some 
degree  of  peribronchitis  are  quite  frequently  found,  especially  in 
infants. 

Physical  Signs. — Auscultation  may  be  negative  at  first,  but  with 
mcreasmg  secretion  bronchial  fremitus  is  present.  Percussion  is  also  of 
little  assistance  except  for  the  early  detection  of  a  possible  pneu- 
monia. Sometimes  there  is  some  hyperresonance  due  to  a  transitory 
emphysema  over  the  border  of  the  lungs. 

Auscultation  is  usually  of  little  value  as  long  as  the  catarrh  is  dry 
and  is  limited  to  the  trachea  and  the  large  bronchi,  but  sibilant,  whis- 
tling rales  appear  early  in  the  disease  and  are  replaced  within  twelve 
to  twenty-four  hours  by  moist,  bubbling  rales;  these  are  medium  or 
coarse  according  to  the  size  of  the  bronchi  involved.  They  are  most 
distinct  between  the  scapula  and  in  the  intraclavicular  spaces  but 
can  be  heard  all  over  the  chest,  changing  frequently,  and  appearing 
and  disappearing  with  the  paroxysms  of  coughing.  The  vesicular 
murmur  is  feeble,  expiration  is  often  prolonged  and  rather  harsh  over 
the  supra-  and  mtrascapular  region,  simulating  bronchial  breathmg. 

The  base  of  both  Imigs  should  be  carefully  and  frequently  examined 
for  fine,  crepitant  rales,  which  would  indicate  an  incipient  pneumonia. 
The  loud,  wheezing  sounds  sometimes  persist  for  two  or  three  weeks 
following  the  acute  stage.  The  physical  signs  sometimes  very  closely 
resemble  those  of  asthma,  especially  in  the  presence  of  spasmodic  or 
of  asthmatic  elements. 

Symptoms. — The  milder  form,  m  which  the  aiTection  is  limited  to 
the  larger  tubes,  is  very  common  indeed.  It  is  not  serious  in  older 
children,  but  in  infants  there  is  always  danger  of  a  complicating  capil- 
lary bronchitis  or  bronchopneumonia.  AMien  a  catarrh  of  the  upper 
air  passages  extends  to  the  bronchi — as  in  some  children  is  the  case 
after  almost  every  coryza — it  manifests  itself  by  a  cough,  by  slightly 
accelerated  breathing,  and  by  a  further  rise  of  temperature.  It  is 
usually  the  paroxysmal,  tight,  ineffectual,  annoying  cough  which 
attracts  attention;  worse  at  night  at  first,  it  becomes  looser  and  less 
irritating  within  a  few  days.  The  respirations,  often  accompanied 
by  rattling  in  the  late  stage,  may  be  accelerated  to  40  or  50  per  minute. 
The  temperature,  irregular  in  character,  runs  from  100°  to  102°  F. 
for  two  or  three  days,  then  sinks  below  100°  F.,  and  usually  returns 
to  the  normal  within  a  week.  There  is  no  marked  constitutional 
disturbance;  in  fact,  there  is  very  little  danger  except  in  young  and 
delicate  infants,  older  children  being  hardly  sick  enough  for  bed  after 
the  first  or  second  day.  There  is,  however,  a  moderate  degree  of  rest- 
lessness, depending  upon  the  severity  of  the  cough,  some  substernal 
soreness  in  older  children,  also  gastro-intestinal  symptoms  with  vomit- 
ing and  diarrhea  m  the  very  young  patient. 

Children  under  five  years  of  age  do  not  expectorate  unless  they  are 
"  experienced  coughers,"  but  they  swallow  the  secretion  as  it  is  coughed 
up.     In  older  patients  the  expectoration  consists  of  a. white,  frothy 


ACUTE  BRONCHITIS  411 

mucus  duriirg  the  first  few  days,  wliicli  later  on  becomes  more  abundant 
and  of  a  yellowish-green  tinge. 

In  the  more  severe  types  of  simple  bronchitis  all  the  symjjtoms  are 
more  pronounced,  due  to  the  involvement  of  the  smaller  tubes.  The 
onset  may  be  gradual,  following  a  rhinitis  or  a  pharyngitis,  with  pro- 
dromal fatigue,  malaise  and  headache,  but  it  is  often  abrupt,  accom- 
panied by  chills,  or  by  convulsions  in  infants,  and  by  fever,  pain  in 
the  head,  the  back  and  the  chest,  and  a  dry  cough  closely  resembling 
that  of  incipient  pneumonia.  The  cough,  the  most  prominent  symp- 
tom, is  absent  only  in  weak  infants,  and  is  of  the  same  character  as  in 
the  milder  cases,  except  that  it  is  considerably  more  severe  and  more 
troublesome,  and  at  times,  is  associated  with  pain  or  even  vomiting. 
It  not  infrequently  lasts  some  time  after  all  the  physical  signs  have 
disappeared.  In  the  early  stages  the  expectoration  is  occasionally 
blood-streaked  and  later  becomes  profuse  and  mucopurulent,  caus- 
ing  a  persistent   cough,   especially   in   the  morning   on   awakening. 

The  respirations  are  hurried,  perhaps  somewhat  labored,  though 
ordinarily  there  is  no  evidence  of  real  dyspnea.  But,  as  the  inflam- 
matory process  extends  deeper  into  the  bronchial  tree,  respiration 
becomes  more  rapid  and  superficial.  In  children  40  or  50  respirations 
per  minute  are  not  necessarily  serious,  but  with  an  increase  to  60  or 
80,  accompanied  by  flaring  of  the  alee  nasi  and  participation  of  the 
accessory  respiratory  muscles,  together  with  inspu-atory  retraction, 
marked  cyanosis  and  prostration,  and  unduly  prolonged  expiration, 
a  bronchopneumonia,  or  so-called  capillary  bronchitis,  may  be  appre- 
hended. Weak  and  very  young  infants  are  the  only  exceptions  to  this 
rule,  inasmuch  as  with  them  dyspnea  and  recession  of  the  soft  parts 
occur  even  in  an  uncomplicated  bronchitis.  Respiratory  failure  and 
suffocative  attacks  may  develop  quite  suddenly,  especially  in  infants 
under  six  months  of  age,  who  are  unable  to  empty  their  tubes  of  secre- 
tion by  coughing  or  by  crying.  The  irregular,  superficial  breathing 
and  the  clammy,  cyanotic  skin  produce  dulness,  apathy,  and  stupor, 
and  unless  promptly  relieved  convulsions  and  death  may  follow^  within 
a  few  hours.  The  temperature  is  not  characteristic;  during  the  first 
few  days  it  runs  up  to  102°  or.  104°  F.,  but  if  no  complications  arise 
it  gradualh'  falls  to  normal  within  a  week.  The  constitutional  symp- 
toms abate  with  the  fall  of  temperature  and  seldom  cause  anxiety 
except  for  the  first  twenty-four  to  thirty-six  hours.  Inspection  of  the 
bared  chest  shows  nothing  beyond  rapid  breathing  and  slight  inspira- 
tory retraction  of  the  soft  parts.  When  exaggerated  (except  in  very 
young  or  weak  infants),  the  latter  sign,  together  with  increasing  dyspnea 
and  cyanosis,  becomes  an  important  danger  signal  of  incipient  broncho- 
pneumonia. 

Prophylaxis. — All  infants  and  children,  especially  those  sufi^ering 
from  syphilis,  rickets,  and  nutritional  distiubances,  should  be  care- 
fully kept  from  close  contact  with  persons  afflicted  wdth  colds,  rhinitis, 
tonsillitis,  grippe,  etc.  If  in  spite  of  all  precautions  they  become 
aftected  with  catarrh  of  the  upper  respiratory  passages,  treatment 


412  DISEASES  OF   THE  RESPIRATORY   TRACT 

should  be  prompt  and  careful,  and  should  be  continued  until  con- 
valescence is  completely  established,  for  tuberculosis  may  develop 
in  the  inflamed  bronchial  glands.  Adenoids  and  diseased  tonsils 
should  be  removed  when  necessary,  preferably  during  the  warm  season 
of  the  year. 

Treatment. — While  fresh  air  is  of  the  greatest  importance,  the 
advantage  of  mhalmg  a  great  deal  of  cold  air  has  not  yet  been  demon- 
strated. The  sleeping  apartments  of  susceptible  children  should  be 
well  ventilated  but  the  temperatm-e  should  not  register  less  than  60° 
F.  if  possible.  During  cold  weather  the  clothing  should  be  sufficiently 
warm  but  not  cumbrous,  and  the  house  should  be  kept  at  as  equable 
a  temperature  as  possible.  A  warm  dr}^  climate  (sometimes  mild  sea- 
ah  does  equally  well)  is  a  boon  during  the  winter  months,  especially 
for  the  child  with  a  tendency  to  pulmonary  disease  or  one  with  tuber- 
cular antecedents.  Generally  speaking,  the  mild  case  requires  little 
treatment  beyond  careful  nursing  and  feeding,  while  the  more  severe 
type  must  be  treated  as  bronchopneumonia.  As  long  as  there  is  fever, 
the  patient  should  be  confined  to  bed  in  a  bright,  large  room,  preferably 
with  an  open  fireplace,  to  ensure  thorough  ventilation,  and  a  screen 
as  a  protection  against  draughts.  To  prevent  hypostatic  congestion, 
delicate  infants  must  be  frequently  taken  up,  or,  at  least,  then  position 
must  be  changed.  They  should  be  kept  warm,  though  this  does  not 
mean  bundling  them  up  in  blankets  or  warm  shawls,  as  is  frequently 
done. 

The  Diet. — ^The  nursing  infant  has  a  much  better  chance  of  recovery 
than  the  bottle-fed  baby.  If  its  temperatme  rises  above  100°  F., 
and  the  little  one  is  restless  and  irritable,  it  may  be  advisable  to 
shorten  the  time  of  nm-sing  to  one-third  or  one-half  the  usual  time, 
and  give  a  few  ounces  of  sweetened  v/ater  before  nursing.  For  bottle- 
fed  babies  it  is  well  to  reduce  the  strength  of  the  milk  formula  and  to 
give  plain  boiled  or  slightly  alkaline  water  between  feedings.  Older 
children,  while  confined  to  bed,  may  be  allowed  a  light  diet  consistmg 
of  toast,  milk,  cocoa,  broths,  gruels,  and  fruit  juices. 

While  pure  air,  the  importance  of  which  has  already  been  empha- 
sized, usually  contams  enough  moistme,  inhalations  of  medicated 
steam  for  half  an  hour  at  a  time  and  repeated  at  intervals  of  several 
hours  are  of  great  ser\'ice  in  the  treatment  of  acute  bronchitis.  Creo- 
sote, 10  drops  to  a  quart  of  water,  seems  the  best,  but  benzoin  and 
eucalyptus  have  also  proved  useful.  A  tent  may  be  improvised  with 
sheets  spread  over  the  top  and  sides  of  the  child's  bed,  and  the  nozzle 
of  the  croup-kettle,  from  which  the  steam  flows,  introduced  within  at 
a  safe  distance  from  the  face  and  head  of  the  child.  Fresh  air  is 
admitted  from  time  to  time  by  raismg  the  sheet. 

Durmg  the  first  few  days  counter-irritation  affords  one  of  the  most 
efficacious  means  of  brmgmg  the  blood  to  the  sm-face  and  thereby 
relieving  pulmonary  congestion.  A  paste  made  of  one  part  of  mustard 
and  three  parts  of  flour  mixed  with  warm  water  and  the  white  of  an 
egg,  and  spread  one-eighth  of  an  inch  thick  on  a  piece  of  old  linen, 


ACUTE  BRONCHITIS  413 

cheesecloth,  or  musUn,  is  appUed  to  the  chest  between  hneii  cloths 
and  left  in  place  until  the  skin  is  well  reddened.  After  its  removal, 
vaseline,  or,  better,  talcum  powder  gently  applied  will  relieve  the 
burning  sensation.  The  hot  mustard  bath,  h  ounce  of  mustard  to 
6  gallons  of  water  at  a  temperature  of  107°  to  110°  F.,  is  especially 
useful  when  the  rapid  respirations  and  the  cold  extremities  indicate 
an  impending  bronchopneumonia.  The  hot  mustard  pack  (a  sheet 
wrung  out  of  hot  mustard  water)  sometimes  proves  equally  useful. 
These  procedures  can  be  repeated  every  four  to  eight  hours;  should 
the  skin  become  very  sensitive,  the  proportion  of  mustard  may  be 
reduced. 

An  old  remedy  of  great  value  in  some  cases  is  dry-cupping  over  the 
chest  and  the  back  from  five  to  ten  minutes  at  a  time;  this  can  be 
repeated  every  few  hours  if  necessary. 

Drugs. — ^The  treatment  of  bronchitis  by  drugs  is  entirely  symptomatic 
and  unimportant.  Of  course,  an  initial  purge  of  castor  oil,  repeated 
every  thi-ee  to  four  days,  is  good  in  helping  to  relieve  the  intestinal 
canal  of  the  swallowed  mucopurulent  materials.  During  the  first 
stage,  characterized  by  a  dry  cough  and  rough  breathing,  castor  oil 
and  syrup  of  ipecac,  2  to  3  drops  each  for  infants,  and  4  to  5  drops 
for  children  three  years  old,  repeated  every  two  to  three  hours  for  the 
first  three  days,  will  help  to  liquefy  the  secretions  and  lower  the  fever. 
It  would  be  injudicious  to  suppress  the  cough;  but,  if  very  distressing, 
the  following  simple  prescription  may  add  to  the  patient's  comfort: 

I^ — Pot.  brom gr.  1 

Tinct.  bellad TTl  xv 

Glycer f3  ij 

Elix.-lact.  peps q.  s.  gij 

One  f3  every  three  hours  for  a  child  one  year  old. 

For  older  children,  tinctura  opii  camphorata,  1  to  2  fluidrams,  may 
be  added.    Or  a  tablet  or  a  powder  may  be  given  as  follows : 

At  age  of  At  age  of  one  After 

six  months.  to  three  years,  three  years. 

I^ — Tartar  emetic jio                    Too  sV 

Powdered  ipecac -^                      -^q  2V 

Ammon.  chlor x                        h  1 

For  a  severe  cough  add  Dover's  powder          -g-                        \  h      ■ 
Two-hour  intervals,  eight  doses  in  twenty-four  hours. 

Antipyretics  are  hardly  ever  needed,  as  the  temperature  can  be  con- 
trolled by  warm  tub  or  sponge  baths,  which  have  the  additional  advan- 
tage of  quieting  the  nervous  system  and  stimulating  the  action  of  the 
skin.  Emetics,  |  to  1  dram  of  either  the  wine  or  the  syrup  of  ipecac, 
were  formerly  used  extensively  for  clearmg  out  the  tubes,  but  they 
are  very  depressing,  and  only  in  exceptional  cases  should  they  be 
given  to  children  under  two  years  of  age.  Guaiacol  in  a  10  per  cent, 
ointment  is  easily  absorbed  by  the  delicate  skin  of  an  infant,  and  when 
so  used  does  not  cause  any  digestive  disturbance.  Quinine,  still 
believed  by  many  to  be  anticatarrhal,  can  be  given  by  rectum  in  sup- 
positories. 


■iU  DISEASES  OF   THE  RESPIRATORY   TRACT 


DISEASES   OF   THE   LUNGS. 


PNEUMONIA. 

In  early  life  the  lungs,  more  frequently  than  any  other  organs,  are 
attacked  by  acute  or  subacute  inflammation,  either  as  a  primary  aftec- 
tion  or  secondary  to  acute  infections.  The  pathology  and  symptoms 
of  the  inflammatory  process  vary  according  to  the  pathogenic  organ- 
isms present  and  the  extent  of  the  lesions.  The  two  leading  types  are: 
(1)  lobar,  flbrinous  or  croupous  pneumonia,  a  sharply  circumscribed, 
inflammatory  process  involving  an  entire  lobe  or  the  greater  portion 
of  it,  without  affecting  the  walls  of  the  bronchioles  and  the  alveolar 
septa.  Both  the  onset  and  the  termination  are  rather  sudden,  the 
disease  running  its  course  within  a  few  days;  (2)  the  lobular  t^-pe — 
bronchopneumonia — involving  the  walls  of  the  bronchi  as  well  as  the 
individual  lobules  of  the  lungs,  and  forming  small  irregularly  dis- 
tributed areas  of  consolidation.  The  exudate  is  composed  mamly 
of  cells  with  very  little  fibrin.  The  duration  and  course  of  this  type 
are  more  or  less  indefinite  and  the  termination  takes  place  by  lysis. 
In  typical  cases,  these  two  types  are  quite  distinct,  but  intermediate 
forms  may  occur,  especially  durmg  the  second  and  third  years  of  life, 
more  or  less  resembling  both  types. 

Lobar  Pneumonia. — This  form,  though  rare  in  infants,  is  not  at  all 
uncommon  after  the  first  year.  It  is  an  acute  infectious  disease, 
running  a  well-defined  coiu-se,  and  differing  in  no  essential  details 
from  the  adult  type.  In  typical  cases  pneumococci  (diplococci  pneu- 
monitie  of  Frankel  or  of  Weichselbaum)  are  often  found  in  the  blood 
and  in  great  numbers  in  the  lungs,  either  as  pure  cultures,  or  predom- 
inating over  the  associated  streptococci  and  staphylococci. 

Pneumococci  are  normally  present  in  the  saliva  and  on  the  mucous 
membrane  of  the  respiratory  passages  of  healthy  children;  it  is,  there- 
fore, self-evident  that  they  incite  disease  only  when  the  local  or  the 
general  powers  of  resistance  are  lowered.  Traumatic  and  other 
predisposing  influences  naturally  also  play  an  etiological  role;  a  blow 
on  the  chest,  a  fall,  fatigue,  the  mhalation  of  irritating  vapors,  and, 
above  all,  undue  exposure  to  raw  winds  and  inclement  weather,  are  no 
doubt  responsible  for  precipitating  many  an  attack.  Fully  two-thirds 
of  all  cases  occur  during  the  winter  and  early  spring  months,  especially 
after  a  sudden  fall  of  temperature  accompanied  by  wind  and  rain  that 
follows  a  period  of  depressing  heat — conditions  that  account  for 
lobar  pneumonia  being  spoken  of  as  a  "house  disease."  The  disorder 
occasionally  follows  grippe,  typhoid  fever,  or  whooping-cough.  As 
a  rule  it  affects  children  previously  healthy ;  that  is  to  say,  if  a  healthy 
child  contracts  pneumonia  it  is  usually  of  the  lobar  type.  As  in 
adults,  repeated  attacks  within  a  year  may  be  attributed  to  a  family 
tendency  to  the  disease.  Boys  are  more  often  affected  than  girls,  prob- 
ably because  they  are  more  likely  to  be  exposed  to  weather  conditions. 


PNEUMONIA  415 

Morbid  Anatomy. — The  anatomical  changes,  seldom  seen  postmortem 
on  account  of  the  low  mortality  of  the  disease  in  children,  closely 
resemble  those  of  the  adult  type,  except  that  the  line  of  demarcation 
is  less  well  defined,  because  the  pneumococcus  may  produce  either 
pneumonia  or  bronchopneumonia  or  both  at  one  time,  together  with 
a  more  or  less  pronounced  pleurisy.  Generally  an  entire  lobe  or  the 
great  part  of  it  is  affected,  but  several  lobes,  both  apices,  or  a  whole 
lung  may  be  involved. 

During  the  first  stage — that  of  congestion — which  may  last  from 
a  few  hours  to  several  days,  the  epithelial  lining  of  the  alveoli  becomes 
turbid  and  swollen  owing  to  the  rich  fibrinous  exudate  that  pours 
into  them.  The  second  stage  is  that  of  red  hepatization,  so  called 
because  the  affected  portion  of  the  lung  resembles  the  liver,  being  red, 
heavy,  tough,  and  granular  on  section  due  to  fibrin  blocks  in  the 
alveoli.  It  may  last  anywhere  from  a  few  days  to  one  or  two  weeks. 
This  is  followed  by  a  shorter  third  stage — that  of  gray  hepatization. 
The  lung  then  appears  bulky,  soft,  yellow  and  bloodless,  with  costal 
imprints.  The  contents  of  the  alveoli  gradually  disappear  by  absorp- 
tion rather  than  by  expectoration.  Resolution  sets  in  with  the  fall 
of  the  temperature  or  soon  after,  and  is  complete  in  about  a  week.  In 
addition  to  these  pulmonary  changes  the  mucous  membrane  of  the 
neighboring  bronchi  as  well  as  of  the  pleura  shows  signs  of  inflamma- 
tion. Pathological  changes,  due  to  complications,  such  as  fibrinous 
or  purulent  pericarditis,  especially  in  left-sided  pneumonia  with 
pleurisy,  or,  more  rarely,  pneumococcic  meningitis,  peritonitis,  ar- 
thritis, may  become  manifest  before,  during,  or  after  the  attack  of 
pneumonia. 

Physical  Signs. — The  little  patient  is  apt  to  be  restless  and  irritable, 
and  examination  is  not  always  easy.  Nevertheless  it  should  be 
repeated  at  frequent  intervals,  because  consolidation  with  all  its  con- 
comitant signs  m_ay  appear  within  a  few  hours  after  a  negative  finding. 
Sometimes  the  only  indications  in  an  otherwise  typical  attack  are  a 
brief  impairment  of  resonance  and  a  few  rales,  and  again  flushed  cheeks, 
herpes  of  the  lips  and  the  nose,  short,  rapid,  superficial  respiration, 
the  flaring  alee  nasi,  and  possibly  a  deficient  expansion  of  the  aft'ected 
side  may  give  a  clue  as  to  the  correct  diagnosis,  when  for  days  and 
even  up  to  the  crisis  the  characteristic  physical  signs  are  delayed. 
Usually,  however,  as  in  the  adult  type,  the  three  stages  of  congestion, 
consolidation,  and  resolution  also  occur  in  children. 

Percussion. — Percussion  of  the  bases  is,  of  course,  a  routine  procedure, 
but  it  is  very  important  not  to  omit  an  examination  high  up  in  the 
axillar.y  and  the  infraclavicular  regions.  Impaired  resonance  or  slight 
dulness  may  often  be  elicited  over  the  affected  area,  and  a  somewhat 
increased  resonance  over  the  rest  of  the  lung,  according  to  the  dimin- 
ished or  increased  amount  of  air  entering  the  lungs.  While  dulness 
is  likely  to  be  absent  in  the  infant,  tympany  may  be  obtained  even 
over  a  consolidated  lung  when  it  overlies  a  distended  viscus,  the 
stomach,  for  instance.    The  tactile  vocal  fremitus  is  of  little  diagnostic 


416  DISEASES  OF   THE  RESPIRATORY   TRACT 

value  in  children,  as  it  would  be  altogether  absent  over  the  area  of  an 
occluded  bronchus  on  account  of  their  thin,  high-pitched  voices. 

Auscultation. — The  vesicular  murmur  is  very  early  diminished  over 
the  affected  portion,  and  breathing  over  the  opposite  lung  becomes 
harsher.  This  puerile  respiration,  due  to  vicarious  emphysema,  must 
not  be  mistaken  for  bronchial  breathing,  which,  as  is  well  known, 
lacks  the  vesicular  element  and  is  more  intensive  on  expiration. 
With  the  inverted  type  of  breathing,  so  often  present  in  pneumonia, 
it  may,  however,  give  the  impression  of  being  louder  on  inspiration 
than  on  expiration.  Bronchial  breathing  and  bronchophony  over 
a  sharply  defined  consolidated  portion  are  most  valuable  signs;  they 
may  often  be  heard  as  early  as  the  second  day  in  basal  pneumonia, 
and  by  the  fourth  or  fifth  day  are  usually  audible  over  the  spine  of 
the  scapula  in  apical  cases. 

In  order  to  bring  out  these  signs  more  clearly  it  may  be  necessary 
to  cause  deep  breathing  by  inducing  coughing  or  crying,  or  by  having 
the  child  lie  on  one  side  while  examining  the  other,  thus  allowing  the 
air  to  enter  more  freely.  In  this  way  a  high-pitched,  tubular  breathing 
and  crepitation  may  be  revealed  which  at  once  clinch  the  diagnosis. 
This  crepitation  is  best  heard  at  the  end  of  inspiration,  either  as  a 
crepitus  indux  disappearing  with  consolidation,  or  as  a  crepitus  redux 
reappearing  with  resolution;  but  medium  or  coarse  rales  are  much 
more  common  in  children.  Very  often  when  one  lung  is  affected,  these 
signs  are  also  audible  over  the  other  side.  This  is  merely  due  to 
transmission;  the  faint  character  of  the  abnormal  sounds  as  well  as 
the  absence  of  impaired  resonance  should  be  sufficient  to  prevent  a 
mistaken  diagnosis  of  double  pneumonia.  Occlusion  of  a  bronchus 
may  produce  such  complete  absence  of  all  breath  sounds  as  to  suggest 
the  presence  of  a  fluid.  Rales  and  a  pleuritic  friction  rub  are  usually 
absent  during  the  stage  of  consolidation,  while  during  resolution  the 
signs  of  consolidation  disappear  gradually.  The  tubular  quality  of 
the  expirations  and  all  kinds  of  moist  rales  are  gradually  replaced  by 
a  vesicular  murmur,  and  friction  sounds  are  also  sometimes  heard. 
The  physical  signs  clear  up  with  remarkable  rapidity,  as  a  rule  within 
a  week,  but  occasionally  a  slightly  diminished  resonance  and  a  feeble 
vesicular  murmur  may  persist  for  several  weeks. 

Symptoms. — By  the  second  or  third  day  herpes  of  the  lips  or  the 
nose  usually  appears,  the  tongue  shows  a  whitish  or  yellowish  coat, 
the  temperature  and  respiration  continue  high  and  rapid,  and  the 
bowels  are  usually  constipated.  About  this  time  the  physical  signs 
also  set  in,  although  they  may  be  delayed  for  a  few  days.  Toward  the 
seventh  day  all  the  symptoms  are  aggravated  and  alarming,  perhaps 
with  severe  delirium,  when  the  crisis  occurs  with  its  sudden  change. 
The  fever  abates,  the  body  becomes  moist  with  a  warm  perspiration, 
the  cough  grows  looser,  respiration  less  rapid,  and  after  a  quiet 
sleep  the  child  awakens  refreshed,  with  a  slow  pulse  and  often  a  sub- 
normal temperature.  Unless  the  inflammatory  process  spreads  to 
another  lobe  or  a  complication  arises,  the  tongue  clears  and  the  appetite 


PNEUMONIA  417 

returns.  The  child  now  wants  to  sit  up  in  bed,  and  at  the  end  of  the 
second  week  recovery  seems  estabhshed  except,  perhaps,  for  a  few 
rales  and  a  slightly  impaired  resonance  over  the  affected  area. 

In  children  from  seven  to  eight  years  of  age  the  clinical  picture 
closely  resembles  that  of  the  adult,  but  younger  patients  differ  in  the 
ease  with  which  the  immature  organism,  especially  the  nervous  sys-. 
tem,  is  upset.  The  constitutional  symptoms  seem  to  depend  not  so 
much  on  the  extent  or  the  seat  of  the  local  affection  as  on  the  toxemia 
produced.  This  may  be  meningeal,  gastro-intestinal,  migratory,  or 
nephritic.  As  in  other  infectious  diseases,  abortive  cases  are  occasion- 
ally observed.  At  the  onset  these  present  all  the  signs  of  the  first 
stage  of  pneumonia,  but  clear. up  so  quickly  that  even  the  keenest 
observer  may  well  doubt  the  correctness  of  his  diagnosis.  Some  mild 
but  indubitable  cases  may  last  only  three  or  four  days,  but  typical 
lobar  pneumonia  in  childhood  runs  a  definite  course  of  at  least  five  to 
nine  days.  After  a  few  hours,  sometimes  even  days,  of  prodromal 
lassitude,  discomfort,  or  a  slight  cold,  profuse  and  sometimes  repeated 
vomiting  suddenly  takes  place.  This  may  be  accompanied  by  diarrhea, 
chilly  sensations,  epistaxis,  or  even  convulsions.  The  temperature 
rises  sharply  to  103°  or  104°  F.,  the  child  looks  ill,  appears  heavy  and 
dull,  refuses  food,  and  is  easily  persuaded  to  go  to  bed.  It  may  complain 
of  headache  or  of  earache,  and  also  of  severe  abdominal  pain  suggest- 
ing appendicitis;  sharp  costal  pain,  however,  is  a  rare  symptom  in 
children  under  six  years  of  age.  The  next  day  the  fever  continues 
high,  the  cheeks  are  flushed,  the  skin  is  burning  hot,  the  eyes  sparkle, 
the  alse  nasi  vibrate;  the  child,  though  willing  to  stay  in  bed,  is  rather 
restless;  and  during  the  night  it  may  be  drowsy  or  delirious,  breath- 
ing rapidly,  with  a  short  expiratory  moan  or  grunt.  The  short,  dry 
cough,  if  present,  is  often  very  slight  at  first,  though  occasionally  it 
may  be  so  painful  as  to  induce  crying,  but  it  is  not  followed  by 
expectoration.  Whatever  sputum  can  be  obtained  with  a  swab  shows 
the  typical,  characteristic,  tenaciousness  and  rusty  color. 

The  facial  expression  appears  neither  anxious  nor  distressed  in 
spite  of  the  rapid  respiration.  The  cheeks  are  not  alw^ays  flushed — 
in  fact,  sometimes  there  is  marked  pallor.  Herpes  of  the  lips  and  the 
nose  is  frequently  absent  in  infants  under  one  year  of  age.  As  a  rule, 
there  is  no  true  dyspnea,  the  accessory  muscles  remain  inactive,  but 
the  breathing  is  shallow  and  mainly  abdominal,  sometimes  irregular, 
and  always  disproportionally  rapid  (40  to  60  or  more  respirations  per 
minute)  compared  to  the  pulse  rate  and  the  temperature.  The 
cardiorespiratory  ratio  is,  however,  not  so  significant  as  in  adults  owing 
to  the  ease  with  which  the  pulse  in  children  is  accelerated  for  any 
slight  cause.  An  expiratory  grunt  or  moan  with  the  pause  after  inspira- 
tion is  often  observed.  The  range  of  temperature  is  hregular  in  infants, 
oscillating  one  to  three  degrees  or  more,  but  in  robust  and  older  chil- 
dren it  often  shows  the  adult  type — sudden  rise  to  103°  to  105°  F., 
with  slight  diurnal  variations,  finally  ending  by  crisis  on  the  fifth, 
seventh  or  ninth  day,  unless  the  inflammatory  process  spreads  or 
27 


418  DISEASES  OF   THE  RESPIRATORY   TRACT 

complications  arise.  In  such  cases  it  may  not  end  before  the  four- 
teenth day,  and  then  by  lysis. 

Pseiidocrises  are  a  good  omen,  and  are  much  more  common  in  chil- 
dren than  in  adults.  The  inflammation  of  the  lung  itself  does  not 
seem  to  be  the  direct  cause  of  the  fever  because  the  temperature  often 
■reaches  its  maximum  and  falls  before  there  is  any  evidence  of  change 
in  the  lungs. 

The  Pulse. — The  pulse,  at  fu'st  full,  boundmg,  and  slightly  accel- 
erated, becomes  small,  rapid,  irregular,  and  of  low  tension,  as  the 
toxemia  increases;  this  together  with  the  cyanosis  and  the  venous 
pulsation  indicating  a  weakened  heart. 

Gastro-intestinal  Symptoms. — Besides  the  furred  tongue,  the  failing 
appetite,  the  diarrhea  or  constipation,  jaundice  and  vomiting  may 
be  early  symptoms.  Meteorism,  or  abdommal  distention  may  last 
throughout  the  course  of  the  attack  and  are  particularly  distressing 
because  they  embarrass  cardiac  and  pulmonary  action. 

Cerebral  Symptoms. — These  seem  to  be  dependent  more  on  the 
degree  of  fever  and  the  virulence  of  infection  than  upon  the  par- 
ticular portion  of  the  lung  affected.  They  may  vary  from  slight 
wandering  to  active  delirium  with  incontinence  of  the  feces  and  the 
urine.  In  infants  and  young  children  unable  to  formulate  their 
complaints,  restlessness,  muscular  twitching,  and  a  retraction  of  the 
head  may  sometimes  be  so  severe  as  to  simulate  cerebrospinal  menin- 
gitis, while  again  restlessness,  apathy,  and,  later,  drowsiness  are  the 
only  cerebral  manifestations. 

The  Crisis. — The  crisis  usually  occurs  between  the  fifth  and  the 
eighth  day  of  the  disease,  or  earlier  in  exceptional  cases,  though  some- 
times it  sets  in  as  late  as  the  ninth  or  tenth  day.  Should  the  fever 
continue  beyond  that  time  it  is  likely  to  end  by  lysis.  After  the  criti- 
cal fall  the  temperature  may  be  subnormal  for  a  few  days,  and  although 
the  danger  of  collapse  in  children  is  less  than  in  the  adult,  the  patient 
should  be  watched  wath  special  care  during  this  time. 

The  Blood. — From  the  time  of  the  first  chill  the  leukocytes  increase 
rapidly  up  to  40,000  or  70,000.  The  count  returns  to  the  normal 
number  a  few  days  after  the  crisis,  but  it  may  persist  high  for  weeks 
in  complicated  cases  or  when  resolution  is  delayed.  While  a  low  leuko- 
cytosis indicates  reduced  resistance  and  augurs  ill,  a  high  white  cell 
count  is  not  necessarily  a  favorable  prognostic  sign.  Pneumococci 
are  found  in  the  blood  cultures  in  about  50  per  cent,  of  all  cases  even 
before  the  appearance  of  the  characteristic  physical  signs  in  the  lungs. 

The  Urine. — ^The  urine,  as  in  all  fevers,  is  scant  and  dark,  with  a 
high  specific  gravity  and  increased  acidity,  and  contams  casts  and  a 
trace  of  albumin.  The  chlorides  are  reduced,  or  even  absent,  but 
reappear  at  the  time  of  the.  crisis,  when  the  total  quantity  of  urine 
is  also  greatly  increased. 

Diagnosis. — Diagnosis  is  clear  in  the  typical  case;  but  in  the  atypical 
case,  the  late  appearance  of  the  characteristic  physical  signs  and  the 
great  variety  of  general  symptoms  may  puzzle  the  physician  for  several 


PNEUMONIA  419 

days,  unless  the  diagnosis  is  definitely  established  by  a  bacteriological 
examination  of  the  sputum. 

The  most  common  error  is  to  mistake  pneumonia  for  some  other 
disease  rather  than  the  reverse.  Considering  how  frequently  this 
mistake  is  made  in  children,  a  contmuously  high  temperature,  with 
rapid  respirations  and  marked  leukocytosis,  should  arouse  a  suspicion 
of  pneumonia,  no  matter  what  the  other  symptoms  may  be.  A  careful 
search  for  the  physical  signs  high  up  in  the  axilla  may  often  be  of  use 
in  establishing  the  diagnosis. 

The  onset  of  scarlet  fever,  tonsillitis,  gastro-intestinal  disturbances, 
and  malaria  may  resemble  that  of  pneumonia;  but  the  appearance 
of  the  characteristic  rash  on  the  second  day  in  scarlet  fever,  the 
aggravation  of  local  symptoms  in  tonsillitis,  the  rapid  decline  of  fever, 
as  well  as  the  improvement  in  the  constitutional  symptoms  produced 
by  laxatives  and  proper  feeding  in  gastro-enteritis,  and,  finally,  the 
fact  that  chills  followed  by  a  sharp  rise  in  temperature  and  marked 
leukocytosis  are  rarely  seen  in  malaria,  make  the  differentiation  com- 
paratively easy.  On  the  other  hand,  it  is  often  impossible  during  the 
first  few  days  clearly  to  distinguish  a  bronchitis  with  high  fever  from 
pneumonia.  A  rapid  course  with  severe  dyspnea  and  cyanosis  without 
corresponding  physical  signs  in  the  lungs,  especially  in  the  infant, 
may  suggest  miliary  tuberculosis  until  the  subsequent  course  of  the 
disease,  the  temperature  range,  and  an  examination  of  the  sputum, 
together  with  the  history  of  the  onset,  make  the  diagnosis  clear.  The 
constitutional  symptoms  of  influenza,  if  the  catarrh  of  the  conjunctiva 
and  the  upper  air  passages  is  not  marked,  may  at  first  simulate 
pneumonia,  but  the  appearance  of  marked  leukocytosis  and  of  the 
physical  signs,  as  well  as  the  course  of  the  disease  and  the  bacterio- 
logical findings  in  the  sputum,  soon  dispel  all  doubt.  Initial  vomiting, 
abdominal  pain,  tenderness,  and  distention,  especially  when  asso- 
ciated with  slight  resistance  on  the  right  side,  so  strongly  suggest 
appendicitis,  that  operation  has  actually  been  resorted  to  in  such  cases. 

It  is  therefore  important  to  make  a  careful  examination  in  ever\' 
case.  The  sudden  rise  of  temperature  to  103°  or  104°  F.,  the  con- 
tinuous type  of  the  fever,  the  disproportionately  rapid  respirations, 
the  relaxation  of  the  abdominal  walls  between  respirations,  the  ten- 
derness diminishing  or  disappearing  on  deep  pressure  with  the  flat 
hand,  and  the  possible  cough,  will  put  the  careful  observer  on  his 
guard.  Pneumonia  is  sometimes  masked  by  intense  cerebral  symp- 
toms— vomiting,  convulsions,  delirium  or  stupor,  rigidity  of  the 
muscles  of  the  neck  and  opisthotonos — and  may  be  mistaken  for 
cerebrospinal  meningitis;  in  the  absence  of  the  physical  signs  in  the 
lungs,  it  may  be  several  days  before  a  definite  diagnosis  can  be  made. 
The  difference,  however,  may  be  noted  m  the  absence  of  the  slow, 
intermittent  pulse  and  the  slow  irregular  respirations  as  well  as  of  the 
dilated  pupils  of  meningitis  and  the  signs  of  paralysis.  ■  Another 
difterentiating  factor  is  the  presence  of  the  nervous  symptoms  at  the' 
on,set  of  pneumonia^  while  in  meningitis  they  come  on  so  slowly  that 


420  DISEASES  OF   THE  RESPIRATORY   TRACT 

by  the  time  the  resemblance  between  the  two  ailments  is  closest  the 
physical  signs  in  the  lungs  will  have  made  their  appearance. 

^Mien  t^'phoid  fever  with  a  sudden  onset  and  high  temperature  is 
associated  with  symptoms  of  pulmonary  involvement,  as  is  the  case 
with  children,  the  diagnosis  may  be  doubtful  until  the  presence  of 
leukopenia,  or  of  roseola,  or  a  diazo,  or  a  positive  Widal  reaction  leave 
no  room  for  doubt.  The  physical  signs  of  atypical  cases  of  pleural 
exudation  may  so  closely  resemble  lobar  pneumonia  that  the  diagnosis 
can  be  made  only  by  exploratory  puncture.  In  pleurisy  the  area  of 
dulness  shifts  somewhat  with  a  change  of  position,  and  is  usually 
greater,  while  the  flatness  is  more  marked  behind  and  below,  and 
gradually  increases  instead  of  disappearmg  with  the  decline  of  tem- 
perature. The  greater  resistance  noticed  oh  percussion  over  the 
intercostal  spaces,  their  markedly  unilateral  fulness  or  bulging,  the 
limitations  of  respiratory  excursion,  the  displacement  of  the  heart 
and  perhaps  the  liver,  and,  finally,  egophony,  when  present,  all  favor 
effusion.  ^Miile  the  bronchial  voice  is  distant  and  the  intensity  of  the 
respiratory  sounds  is  diminished  in  the  majority  of  young  patients, 
they  are  not  altogether  abolished  as  in  the  adult.  The  bronchial 
breathing  is  feeble  and  most  marked  at  the  upper  border  of  dulness; 
while  in  pneumonia  it  is  louder  and  most  pronoimced  in  the  area  of 
maximum  dulness. 

Prognosis. — Unless  complications  arise,  pneumonia  is  rarely  fatal 
in  children,  especially  after  the  second  year  (mortality  being  2  to  5 
per  cent.) ;  although  death  may  occur  from  otitis,  meningitis,  cerebral 
abscess,  pericarditis,  pleurisy,  or  toxemia — the  toxms  acting  upon 
the  vasomotor  centres  in  the  medulla  and  on  the  cardiac  muscle  fibers. 
As  a  rule,  the  heart  stands  the  strain  well,  but  fatal  syncope  has  been 
knoT^^l  to  occur  during  convalescence.  In  girls  and  undernourished 
children  resistance  is  diminished;  while  rickets,  heart  lesions,  and 
previous  Imig  affections  distinctly  reduce  the  chances  of  recovery. 
Convulsions  are  comparatively  rare  in  children  over  two  years  of  age; 
but  should  they  occur  toward  the  end  of  the  disease  a  fatal  issue  may 
be  expected.  Neither  a  violent  onset  nor  a  high  temperature,  except 
when  over  106°  F.,  nor  the  severity  of  the  initial  nervous  symptoms 
has  much  prognostic  value. 

Treatment. — A  large,  sunny,  quiet,  well-heated  sick-room,  with  an 
abundance  of  fresh  air  flowing  in  through  windows,  open  both  day 
and  night,  and  an  intelligent  nurse  who  can  be  relied  upon  tactfully 
to  keep  out  visitors,  and  to  watch  the  child  with  special  care  at  the 
time  of  the  crisis,  are  important  m  the  general  management  of  the 
case.  The  hours  for  feedmg  and  medication  should  be  so  arranged 
that  the  patient  can  enjoy  intervals  of  three  to  four  hours  of  perfect 
rest.  ]Milk,  whey,  meat  juice,  albumen-water,  fruit  juices  and  broths, 
will  give  the  required  amount  of  nutriment  and  fluid.  If  given  at 
proper  times,  they  will  not  overtax  the  weakened  digestion,  manifested 
in  most  cases  by  anorexia,  vomiting,  and  diarrhea.  While  a  very 
weak  patient  may  require   gavage  feedmg,   overfeeding  should  be 


PNEUMONIA  421 

avoided,  as  it  is  apt  to  induce  gastro-intestinal  disturbances,  fermenta- 
tion, and  abdominal  distention,  which  may  considerably  increase  the 
resoiratory  difficulty.  The  well-nourished  child  when  attacked  by 
pneumonia  can,  in  the  beginning,  very  well  go  without  food  for  one  or 
two  days  provided  it  is  given  plenty  of  water. 

If  an  ice-bag  is  used  over  the  chest,  the  feet  must  be  kept  warm; 
the  bag  should  be  removed  whenever  the  temperature  falls  below 
100°  F.,  and  not  be  replaced  until  it  has  again  risen  to  102°  F.  How- 
ever, a  child  usually  dislikes  extremely  cold  applications,  and  as  their 
superiority  has  not  been  established  warmth  in  some  form  seems 
preferable.  This  is  applied  by  wringing  a  piece  of  flannel  out  of  hot 
water,  wrapping  it  around  the  thorax,  and  covering  it  snugly  with 
several  layers  of  flannel.  The  procedure  can  be  repeated  at  intervals 
of  a  few  hours  without  disturbing  the  child.  Poultices  are  cumbersome 
and  are  rarely  of  any  benefit.  If  applied  over  the  thorax  they,  by  their 
weight,  tend  to  increase  the  respiratory  difficulty,  although  this  dis- 
advantage is  obviated  by  allowing  the  child  to  lie  upon  the  poultice. 
They  are  occasionally  useful  in  relieving  pain  of  an  associated  pleurisy. 
A  mustard  paste — left  in  place  only  long  enough  to  produce  redness 
but  no  blistering — and  intermittent  stupes  will  relieve  the  pain  and 
combat  pulmonary  congestion  by  reflex  action;  although  dry  cups 
applied  over  the  base  of  the  lungs  are  more  efficacious. 

Notwithstanding  the  fact  that  lobar  pneumonia  is  a  self-limited 
disease  with  a  strong  tendency  to  recovery,  and  that  we  know  of  no 
specific  for  it,  and  that  overmedication  certainly  may  do  harm,  there 
is  no  doubt  that  skilful  treatment  not  infrequently  saves  life  and 
always  relieves  the  suffering  of  the  little  patient.  In  the  ordinary, 
uncomplicated  case  an  initial  cathartic  is  indicated;  this  may  consist 
of  one  or  more  teaspoonfuls  of  castor  oil,  or,  if  nausea  and  vomiting 
prohibit  this,  of  small  doses  of  calomel  followed  by  citrate  of  magnesia. 
The  bowels  should  be  kept  open  throughout  the  entire  course  of  the 
disease,  especially  in  the  very  young,  in  order  to  prevent  abdominal 
distention.  A  simple  mixture  of  camphorated  water  containing 
potassium  citrate  and  sweet  spirits  of  nitre,  given  every  three  to  six 
hours,  may  be  of  advantage  in  getting  rid  of  the  sputum  that  may 
have  been  swallowed.  Expectorants  such  as  ammonia,  ipecac,  or 
squills  can  usually  be  dispensed  with  as  they  seem  to  be  a  frequent 
cause  of  gastro-intestinal  disturbance.  Alcohol  has  lost  much  of  its 
former  popularity,  being  now  chiefly  reserved  as  a  stimulant  during 
the  crisis;  but  weakly,  undernourished  children  need  it  from  the 
onset.  Children  under  two  years  of  age  should  be  given  20  to  30  drops, 
sweetened  and  diluted  in  6  to  8  parts  of  water,  three  times  a  day; 
it  is  especially  indicated  when  the  toxemia  and  the  prostration  are 
marked.  Respiratory  and  circulatory  stimulants  may  be  needed, 
especially  during  or  directly  after  the  crisis,  the  most  valuable  being 
strychnine,  gr.  ^lo  and  atropine,  gr.  ^-q,  aromatic  spirits  of  ammonia, 
gtt.  x,  camphor  monobromate,  grain  |,  caft'ein  citrate,  gr.  J,  and 
soda  benzoate  or  salicylate  in  3-grain  doses.    These  doses  are  suitable 


422  DISEASES  OF   THE  RESPIRATORY   TRACT 

to  a  child  five  years  of  age  and  may  be  repeated  e\'ery  tliree  hours  as 
long  as  may  be  necessary.  Oxygen  inhalations  <lo  good  ser\'ice  when 
there  is  cyanosis  with  very  rapid  respirations. 

Other  symptoms  are  treated  as  they  arise.  Convulsions  can  be 
controlled  by  chloral  hydrate  or  sodium  bromide  administered  by 
mouth  or  by  rectum;  for  sleeplessness,  the  same  drugs,  with  the 
addition  of  cold  applications  to  the  head  are  preferable  to  opiates. 
A  dry,  irritating  cough,  which  does  not  yield  to  wine  of  ipecac,  s>Tup 
of  tolu,  or  tincture  of  belladonna,  may  call  for  small  doses  of  heroin, 
paregoric,  or  codein.  Fever  exceeding  105°  F.,  demands  hydrothera- 
peutic  measures,  which  if  judiciously  applied  not  only  reduce  the 
temperature  but  also  quiet  the  nervous  system  and  stimulate  nutri- 
tion. All  children  do  not  react  equally  to  baths;  as  a  rule,  tepid  or 
moderately  cool  water  is  the  choice,  but  a  cool  pack,  or  a  sponge 
with  alcohol  and  water  may  be  better  in  certain  cases.  The  coal  tar 
derivatives  are,  of  course,  out  of  place  as  antipyretics,  but  for  the 
relief  of  pain,  headache,  nervousness,  and  sleeplessness  in  children 
over  two  years  of  age,  phenacetin  in  small  doses  is  certainly  helpful 
and  is  much  used.  When  the  nervous  symptoms  are  pronounced, 
repeated  warm  baths  at  a  temperature  of  95°  F.  will  usually  prove 
efficacious.  The  child  should  not  be  immersed  above  the  lower  part 
of  the  ribs  when  sitting  in  the  tub.  In  addition  to  this,  for  a  child 
of  two,  a  sedative,  4  to  5  grains  of  bromide  with  1  minim  of  tincture 
of  belladonna  in  elixir  of  lactated  pepsin,  will  be  beneficial.  Opiates, 
besides  being  dangerous,  are  rarely  necessary;  although  codeine,  yV 
grain,  or  camphorated  tincture  of  opium,  5  to  20  drops,  is  occasionally 
permissible  for  children  three  to  five  years  of  age,  in  order  to  relieve 
the  excessive  pain  produced  by  the  cough  or  the  pleurisy. 

During  the  last  few  years,  laboratory  methods  of  treatment  have 
gained  some  prominence.  While  leukocyte  extract  has  not  as  yet 
been  tried  in  a  sufficient  number  of  cases  to  allow  of  any  definite  con- 
clusions, it  appears  that  there  is  a  fairly  constant  reduction  of  tempera- 
ture after  two  to  four  injections.  As  for  pneumococcus  serum,  Rowland 
G.  Freeman  regards  a  dosage  of  100  to  150  c.c.  a  safe  method  for 
combating  pneumonia  in  children.  Very  soon  after  the  injection  the 
majority  of  them  seem  to  brighten  up,  the  appetite  and  color  appear 
improved,  while  the  temperature  is  reduced,  sometimes  markedl\-  so. 
Although  the  condition  of  the  lung  itself  does  not  change  much,  as 
a  rule,  the  average  duration  of  the  disease  as  well  as  the  mortality, 
are  slightly  lowered.  The  reports  as  to  the  value  of  vaccine,  especially 
the  autogenous,  treatment  continue  to  be  contradictory.  Morton 
Illman  gives  400  to  500  millions  of  pneumococcic  stock  vaccine  in 
every  case  of  lobar  pneumonia  as  soon  as  it  has  been  diagnosed,  and 
follows  it  with  a  second,  slightly  smaller,  injection  in  tw^o  or  three 
days.  In  some  of  the  cases  there  is  a  prompt  return  to  normal  tem- 
perature and  a  marked  amelioration  of  all  the  toxic  symptoms;  in 
others,  a  pseudocrisis  takes  place  wnth  a  subsequent  slight  rise  of 
temperature  ending  within  twenty-four  to  forty-eight  hours  by  lysis. 


BRONCHOPNEUMONIA  423 

Finally,  there  are  cases  which  to  all  appearances  are  not  favorably 
influenced  and  which  terminate  in  the  usual  way.  Whe]i  streptococci 
or  the  bacilli  of  Friedlander  are  found  in  cultures  of  the  sputum,  it 
is,  of  course,  necessary  to  add  proportionate  amounts  of  these  to  the 
vaccine  in  order  to  obtain  good  results. 

Convalescence. — A  few  days  after  the  crisis,  when  the  physical 
signs  are  clearing  up,  the  child  may  be  allowed  out  of  bed,  and  after 
the  lapse  of  a  week  may  be  taken  out  of  doors,  provided  the  weather 
be  favorable  and  there  is  no  danger  of  complications.  During  con- 
valescence, warm  clothes,  a  carefully  selected,  nourishing  diet,  and 
plenty  of  fresh  air  are  ordinarily  all  that  is  needed.  If  the  general 
improvement  does  not  progress  steadily,  some  tonic  may  be  required, 
such  as  malt  extract  and  iron,  the  syrup  of  ferrous  iodide,  or  the  like. 

BRONCHOPNEUMONIA. 

The  pathological  condition  described  under  this  name  is  really  a 
syndrome  rather  than  a  clinical  entity  jper  se,  following  more  or  less 
closely  upon  an  infection  of  the  upper  air  passages,  or  arising  in  the 
course  of  certain  infectious  diseases.  Next  to  gastro-intestinal  dis- 
turbances, it  is  the  most  common  and  the  most  serious  trouble  of 
infancy;  its  characteristic  feature  being  an  inflammation  of  the 
respiratory  passages  which  extends  to  the  minute  bronchi  and  adjacent 
alveoli.  The  fact  that  the  latter  are  not  fully  developed  before  the 
third  or  fourth  year  may  partially  explain  the  striking  susceptibility 
of  infants  to  this  affection.  While  rare  during  the  first  six  months, 
about  50  per  cent,  of  all  cases  occur  during  the  first  year,  .30  per  cent, 
during  the  second,  and,  approximately,  10  to  15  per  cent,  in  the  third 
year  of  life.  It  does  not  often  appear  as  a  primary  disease  after  the 
fourth  year,  but  it  may  occur  throughout  childhood  as  a  complication 
of  the  acute  infectious  diseases. 

In  only  about  one-third  of  all  cases  of  bronchopneumonia  is  the 
disease  primary;  as  such  it  is  most  commonly  due  to  the  pneumo- 
coccus,  and  in  older  children  it  probably  manifests  itself  as  lobar 
pneumonia.  In  the  remaining  two-thirds,  nearly  always  due  to  mixed 
infection,  it  is  secondary  to  simple  bronchitis,  measles,  whooping- 
cough,  or  to  influenza,  and  in  delicate  and  in  older  children  to  scarlet 
fever  or  to  diphtheria,  especially  in  the  laryngeal  form  after  intubation 
or  tracheotomy.  No  doubt  a  good  many  of  these  cases  may  be  traced 
to  the  attitude  of  well-meaning  but  uninformed  parents  who,  in  their 
fear  of  colds,  keep  their  children  confined  in  close,  overheated  and 
poorly  ventilated  rooms. 

Poorly  nourished,  rachitic,  or  syphilitic  children,  especially  when 
in  institutions,  are  particularly  predisposed  to  the  disease,  and  should, 
therefore,  be  guarded  from  undue  exposure  during  the  winter  months, 
in  which  bronchitis  and  infectious  diseases  are  prevalent.  Broncho- 
pneumonia is  probably  always  due  to  the  action  of  pneumococci  but 
the  bacilli  of  Friedlander,  and  the  influenza  bacilli,  and  more  rarely 


424  DISEASES  OF   THE  RESPIRATORY   TRACT 

those  of  diphtheria  may  be  found  in  all  possible  combinations  of  pre- 
dominance. Its  severity  is,  however,  not  so  much  dependent  on  the 
particular  organism  as  on  the  soil  jn  which  the  organism  flourishes. 

Pathology. — In  older  children,  typical  lobar  and  bronchopneumonia 
may  at  times  be  quite  as  distinctly  differentiated  as  in  adults,  although 
there  are  cases,  especially  m  children  under  four  years  of  age,  which 
cannot  be  definitely  classified  even  with  the  aid  of  a  microscopic 
examination.  Again,  both  types  may  be  found  in  different  parts  of 
the  Imigs  in  the  same  patient. 

Bilateral  bronchopneumonia  affects  the  posterior  portion  of  the 
lower  lobe  about  five  times  as  frequently  as  it  does  other  parts.  The 
inflammatory  process  spreads  through  the  walls  of  the  bronchioles 
to  the  surrounding  tissues,  which  become  markedly  infiltrated  with 
lymphocytes.  Pus  oozes  from  the  bronchioles  on  pressure,  and  their 
adjacent  alveoli  are  more  or  less  distended  with  epithelial  debris  as 
well  as  with  white  and  perhaps  some  red  blood  corpuscles,  serum, 
and  a  small  amount  of  fibrin.  At  first  these  areas  of  peribronchitis 
are  small — the  size  of  a  pea  or  smaller — and  are  surrounded  by  normal 
or  gray  emphysematous  lung  tissue  appearing  in  the  surface  as  purplish 
foci;  later  they  become  yellowish-gray  and  may  increase  to  the  size 
of  a  nut,  or  by  coalescence  they  may  sometimes  affect  the  greater  part 
of  the  whole  lobe.  The  bronchial  and  tracheal  lymph  glands  are  also 
swollen. 

Symptoms. — There  is  no  regular  course  of  symptoms.  As  most 
cases  of  bronchopneumonia  are  secondary  conditions,  they  are  pre- 
ceded by  febrile  or  afebrile  manifestations  of  catarrh  of  the  nose,  the 
larynx,  the  trachea,  or  the  larger  bronchi,  or  as  complicating  symp- 
toms of  infectious  disease.  The  onset  is  therefore  usually  gradual 
with  unmistakable  pulmonary  signs,  thus  contrasting  with  lobar  pneu- 
monia with  its  often  misleading  initial  abdominal  or  cerebral  symp- 
toms. However,  a  sudden  onset  with  a  sharp  rise  of  temperature, 
vomitmg,  and  anorexia  is  not  rare;  and  in  the  breast-fed  infant  the 
refusal  to  nurse  is  frequently  one  of  the  first  signs  of  the  disturbance  of 
respiration.  The  breathmg  becomes  more  rapid  and  difficult,  and  the 
cough  more  constant.  The  child  appears  very  ill  and  prostrated,  and 
as  the  dyspnea  progresses,  the  cyanosis  and  drowsiness  deepen  and 
the  pulse  and  the  cough  grow  weaker;  finally,  convulsions  and  coma 
may  lead  to  a  fatal  termination  after  an  illness  of  a  week  or  two. 

Fortunately,  more  often  the  outcome  is  a  happier  one.  After  one 
or  two  weeks  a  more  or  less  rapid  abatement  of  all  the  symptoms  is 
followed  by  a  short  pyrexial  period,  and  then  micomplicated  recovery, 
provided,  of  course,  there  is  no  relapse  with  its  signs  of  mvolvement  of 
fresh  areas.  This  may,  natiu-ally,  delay  recovery  for  several  weeks. 
An  increasing  cyanosis  and  respiratory  distress,  a  feeble  cough,  con- 
sequent increased  large  moist  rales  in  the  trachea  and  the  bronchi, 
a  weakened  pulse,  together  with  a  cold,  clammy  skin,  a  dull,  listless, 
drowsy  attitude — all  indicate  that  the  disease  is  progressing  unfavor- 
ably.    On  the  other  hand,  the  fact  that  the  symptoms  do  not  grow 


BRONCHOPNEUMONIA  425 

worse  is  a  favorable  indication.  Improvement  sets  in  as  the  cyanosis 
and  dyspnea  become  less  intense,  the  temperatm-e  gradually  falls, 
while  the  now  effectual  cough  helps  to  clear  the  air  passages;  the 
child  awakens  from  its  lethargy  and  takes  its  food  more  readily. 

TJie  Cough. — The  cough  is  usually  intermittent,  though  sometimes 
it  is  continuous,  dry,  harsh,  and  irritating,  loosening  as  the  mucous 
secretion  increases.  Or  it  may  be  entirely  wanting  for  a  time,  after 
which  it  is  feeble  and  accompanied  by  pronounced  prostration  and 
delirium.  As  already  noted,  young  children  do  not  expectorate  but 
swallow  the  purulent  sputum  and  consequently  often  suffer  from  gastro- 
intestinal disturbances.  It  is  difficult  and  usually  unnecessary  to 
obtain  any  sputum  for  examination.  Vomiting,  although  rare  in  the 
beginning,  is  quite  common  in  the  later  stage.  Diarrhea  and  tympanites 
also  appear  at  this  time,  the  one  exhausting  the  patient's  strength, 
and  the  other  interfering  with  the  unhampered  action  of  the  diaphragm 
and  thus  aggravating  the  dyspnea. 

The  Urine. — The  urine  as  in  all  fevers  contains  a  trace  of  albumin, 
a  few  hyaline  casts,  and  now  and  then  a  granular  cast,  but  it  clears  up 
with  the  general  improvement. 

Resijiration. — As  restlessness,  crying,  and  coughing  completely 
alter  the  respirations,  their  real  character  can  be  judged  only  when  the 
patient  is  quiet.  They  are  irregular  and  frequent,  40  to  60,  or  more, 
accompanied  by  a  short  expiratory  grunt  or  moan.  Extreme  counts 
of  100  or  120  are  probably  due  to  the  action  of  toxms  on  the  respiratory 
centre.  Dyspnea  exists  from  the  onset,  but  varies  in  intensity  accord- 
ing to  the  amount  of  obstruction  offered  to  the  free  entrance  of  air 
into  the  bronchioles  and  the  alveoli,  as  well  as  to  the  pulmonary 
circulation.  It  may  become  so  marked,  and,  with  the  activity  of  the 
auxiliary  muscles  of  the  soft  parts  above  the  clavicle  and  below  the 
ribs,  so  resemble  larjoigeal  stenosis  or  diphtheria,  that,  except  for 
the  absence  of  the  stridor,  one  might  be  tempted  to  perform  intubation 
or  tracheotomy. 

Circulatory  Organs. — The  pulse  rate  is  increased  from  120  to  160  and 
more,  depending  upon  the  height  of  the  fever,  the  extent  of  the 
inflammation,  the  amount  of  toxemia,  and  the  condition  of  the  heart. 
An  affection  of  the  latter  is  a  most  serious  complication.  As  long  as 
the  pulse  continues  full  and  strong,  even  though  it  be  very  rapid,  there 
is  very  little  cause  for  alarm,  but  when  it  becomes  thready,  easily 
compressible,  and  irregular  the  outlook  grows  serious.  A  marked 
obstruction  to  the  pulmonary  circulation  causes  overdistention  of 
the  right  heart,  and  the  resulting  venous  stasis  manifests  itself  in 
cyanosis,  and  swelling  of  the  eyelids,  the  hands  and  the  feet. 

Temperature. — Except  in  very  debilitated  (marantic)  children,  who 
may  have  little  or  no  fever,  the  temperature  ranges  from  101°  to 
105°  F.,  attaining  its  maximum  in  a  week  or  ten  days  and  rumiing 
an  irregular,  markedly  remittent,  even  intermittent  course.  As  a 
rule,  it  terminates  by  lysis;  a  crisis  is  probable  in  those  cases  which 
are  due  chiefly  to  the  pneumococcus.    A  relapse  causes  the  tempera- 


426  DISEASES  OF   THE  RESPIRATORY   TRACT 

tiire  to  rise  again  for  a  few  days,  after  wliicli  it  graduall.N'  returns  to 
normal.  Though  it  is  true  that  diagnosis  is  largely  made  from  the 
clinical  picture,  nevertheless  the  physical  signs  are  important  con- 
firmatory evidence. 

Inspection. — The  character  of  the  breathing  alone  is  frequently 
sufficient  for  a  provisional  diagnosis.  Symptoms  of  dyspnea,  abnor- 
mal activity  of  the  auxiliary  respiratory  muscles,  inspiratory  retrac- 
tion of  the  soft  parts,  the  peripneumonic  groove,  progressive  cyanosis 
with  cold,  blue  extremities  and,  finally,  signs  of  more  or  less  pros- 
tration cdnnot  fail  to  be  recognized. 

Auscultation  is  often  puzzling  on  account  of  the  frequent  changes 
noticed  from  day  to  day.  Usually  both  lungs  are  involved  but  by  no 
means  equally  so.  Dm-ing  the  early  stage,  the  breathing  is  often 
harsh  and  accompanied  by  medium  or  coarse  rales.  After  some  time, 
fine  crepitations  of  the  bronchioles  and  the  alveoli  become  audible, 
disappearing  in  one  place,  reappearing  in  another,  and  being  irregularly 
distributed  in  patches  over  both  lungs  but  principally  over  the  posterior 
bases.  Consolidation  of  larger  areas  is  evidenced  by  bronchial  breath- 
ing and  distinct  broncliophony,  which  are  brought  out  more  clearly 
on  cougliing  or  crying.  It  is  therefore  equally  important  to  auscult 
the  chest  both  while  the  child  is  breathing  quietly  and  while  it  is 
crying.  Often  the  heart  sounds  are  heard  very  distinctly  over  large 
consolidated  patches  of  the  left  lung. 

Percussion. — Early  in  the  disease  the  resonance  is  not  impaired; 
on  the  contrary  the  percussion  note  may  be  somewhat  tympanitic. 
It  may,  however,  be  slightly  diminished  over  patches,  especially  m 
the  lower  posterior  lobes,  this  impairment  becoming  more  marked 
later  when  the  scattered  small  areas  of  consolidation  tend  to  coalesce. 
Real  dulness  is  rare  except  when  larger  areas  are  involved;  these  then 
give  rise  to  signs  similar  to  those  of  lobar  pneumonia,  except  that 
they  appear  later  and  clear  up  more  slowly.  AMien  the  right  heart 
is  embarrassed  by  obstruction  to  the  pulmonarv  circulation,  its  dul- 
ness extends  beyond  the  sternum  to  the  right,  and  with  increasing 
difficulty  in  breathing  the  inferior  border  of  liver  dulness  may  be 
found  to  be  very  much  lowered. 

Diagnosis. — The  cough  and  the  changed  character  of  the  respiration 
indicate  the  lungs  as  the  seat  of  the  disease.  During  the  early  stage 
it  is  often  not  easy  to  distmguish  bronchopneumonia  from  severe 
bronchitis,  since  the  latter  may  also  begm  with  a  fever  of  103°  to  10-i° 
F.  This,  however,  in  bronchitis,  falls  to  100°  or  101°  F.  within  twent^'- 
four  to  forty-eight  hours  and,  in  addition,  only  coarse  rales  are  heard 
over  the  whole  chest,  while  tlie  prostration  and  all  the  other  symptoms, 
with  the  exception  of  the  cough,  are  less  severe  than  in  bronchopneu- 
monia. On  the  other  hand,  the  appearance  of  fine  crepitations,  areas 
of  consolidation,  the  bronchial  breathing,  and  bronchophony  indicate 
the  more  serious  cliaracter  of  the  trouble.  A  localized  bronchitis, 
especially  in  children  under  three  years  of  age,  and  when  accompany- 
ing or  following  measles,   whooping-cough,   or  pronounced  rachitis, 


BRONCHOPNEUMONIA  427 

always  arouses  a  suspicion,  of  broiichopueumouia,  pro\'ided  tliat  acute 
pulmonary  tuberculosis  (particularly  the  caseous  form  which  affects 
the  lower  lobe  in  chiklren)  cau  be  excluded.  The  latter  affection  is 
rare,  but  may  give  rise  to  exactly  the  same  symptoms  and  signs 
except  that  the  areas  do  not  shift  as  in  the  other  forms  of  prolonged 
bronchopneumonia;  it  is,  however,  definitely  determmed  by  the  finding 
of  tubercle  bacilli  in  the  sputum  and  a  family  history  of  tuberculosis. 

It  is  not  difficult  to  differentiate  bronchopneumonia  from  lobar 
pneumonia  in  typical  cases.  A  large  area  of  consolidation  limited  to 
one  lobe  with  definite  dulness,  bronchial  breathing,  and  subcrepitant 
rales  usually  indicates  lobar  pneumonia.  In  bronchopneumonia, 
while  the  dulness  may  be  wanting,  coarse  rales  are  found  over  the 
larger  bronchi  and  crepitant  or  subcrepitant  rales  appear  and  disap- 
pear over  different  parts  of  both  lungs.  In  the  many  atypical  cases, 
where  the  physical  signs  are  not  thus  clearly  defined,  the  clinical  his- 
tory as  to  the  onset,  the  course,  and  the  termination  of  the  symptoms, 
may  help  in  the  differential  diagnosis.  In  fact,  in  the  very  young 
child  the  diagnosis  often  rests  entirely  upon  the  rapid  respirations,  the 
cyanosis,  and  the  prostration.  When  following  either  simple  bron- 
chitis or  that  complicating  the  infectious  fevers,  an  increase  in  these 
symptoms  together  with  a  rise  of  temperature  takes  place  at  least 
twenty-four  hours  before  the  appearance  of  the  physical  signs.  The 
occurrence  of  bronchopneumonia  in  w'eakly  infants  is  not  surprising, 
but  w^e  must  look  for  a  special  reason  w^hen  it  attacks  apparently- 
healthy  children.  With  them  it  may  be  preliminary  to  measles,  or  it 
may  be  masking  a  whooping-cough  of  pneumococcal  or  tubercular  origin. 
In  cases  with  a  markedly  remittent  temperature  and  a  very  slight 
cough,  a  combination  which  occurs  not  infrequently  in  infants,  the 
possibility  of  primary  or  secondary  malaria  can  easily  be  excluded 
by  an  examination  of  the  blood.  Atelectasis  is  uncommon  after  the 
fourth  month,  and  congenital  atelectasis  is  often  impossible  to  diagnose 
in  vim.  It  is  seen  most  commonly  in  delicate  infants  who  were  with 
difficulty  resuscitated  at  birth,  and  the  cyanosis  which  is  a  common 
symptom  is  out  of  proportion  to  the  findings  in  the  lungs. 
,  Complications. — Thrush,  in  delicate  infants,  and  stomatitis  in  older 
children  are  quite  common,  but  true  gastro-enteritis  is  not  a  frequent 
complication  of  bronchopneumonia.  Vomiting  and  diarrhea,  so  often 
seen  at  the  onset,  are,  no  doubt,  chiefly  functional.  There  is  a  certain 
amount  of  emphysema  usually  present,  not  marked  enough,  however, 
to  produce  any  physical  signs.  An  irregular,  remittent,  or  intermittent 
temperature  following  bronchopneumonia  usually  indicates  some  com- 
plication. Pleurisy,  usually  the  pmulent  type,  does  not  occur  as 
frequently  as  in  lobar  pneumonia;  otitis  media  is  rather  common  and 
should  be  looked  for  if  the  child  shows  increased  restlessness,  hrita- 
bility  and  sleeplessness  in  addition  to  the  usual  symptoms.  Meningitis, 
arthritis,  and  purulent  pericarditis  occur  but  rarely. 

Prophylaxis. — Children  should  be  kept  away  from  persons  suffering 
from  a  cold  or  a  sore  throat,  since  a  coryza  or  bronchitis  is  easily 


428  DISEASES  OF   THE  RESPIRATORY   TRACT 

acquired  by  such  contact,  and  may,  in  a  delicate  child,  lead  to  a  fatal 
bronchopneumonia.  If  catarrh  of  the  respiratory  passages  occurs  in 
spite  of  all  precautions,  it  must  not  be  neglected.  It  is  of  great 
advantage  to  protect  children,  at  least  up  to  the  fourth  year,  from 
contracting  measles  or  whooping-cough;  after  this  period  there  is 
less  risk  of  the  dreaded  complication  of  bronchopneumonia.  No 
doubt  it  could  often  be  prevented  if  children  convalescing  from  measles 
or  whooping-cough  were  not  allowed  out  of  doors  before  the  physician 
feels  satisfied  that  there  is  no  further  danger  of  pulmonary  compli- 
cation. There  should,  however,  be  no  lack  of  fresh  air.  ^lore  cases  of 
bronchopneumonia  formerly  followed  the  infectious  fevers,  when  the 
patients  were  kept  in  overheated  rooms  and  in  beds  loaded  with 
blankets,  than  at  present  when  plenty  of  fresh  air  is  the  rule.  While 
primary  cases  of  bronchopneumonia  need  not  necessarily  be  isolated, 
isolation  is  certamly  advisable  when  the  disease  is  secondary  to  infec- 
tious fevers  (measles  and  whooping-coughj ;  these  seem  to  lend  it  a 
special  virulence  or  infectivity  as  evidenced  during  epidemics  in 
measles  wards,  for  example. 

Treatment. — There  is  no  specific  remedy  and  the  general  treatment 
follows  the  line  of  other  febrile  conditions.  It  requires  special  care 
because,  the  disease  being  protracted  and  not  self-limited,  it  is  a 
matter  of  the  greatest  importance  to  conserve  every  bit  of  strength. 
Restlessness,  loss  of  sleep,  indigestion,  and  an  increased  strain  on 
the  heart  cause  so  much  waste  of  vitality  that  it  is  most  essential 
to  make  the  child  comfortable,  not  by  drugs,  however,  but  by  a  good 
sick-room  regime.  This  will  influence  the  course  of  the  disease  con- 
siderably and  save  many  lives. 

The  room,  bared  of  all  umiecessary  furniture,  should  have,  first  and 
foremost,  a  constant  supply  of  fresh — not  necessarily  cold — air.  For 
the  very  young  a  temperature  under  60°  F.  is  hardly  of  advantage, 
while  70°  F.  should  be  the  upper  limit.  As  a  dry  atmosphere  is  irri- 
tating, it  must  be  moistened  from  time  to  time,  by  means  of  a  spray, 
a  croup-kettle,  or  wet  cloths  hung  up  in  the  room.  There  is  a  tendency 
to  overclothe  the  patient;  nothmg  more  than  a  flannel  shirt  and  a 
simple  night-dress  is  required  even  in  winter.  When  older  children 
are  given  the  open-air  treatment,  under  which  the  sleep,  the  appetite, 
and  the  cough  often  show  striking  improA'ement  in  prolonged  cases, 
they  of  course  require  more  clothmg.  The  patient  should  not  be 
allowed  to  lie  on  his  back  constantly,  but  should  be  turned  on  the 
side  or  the  abdomen  several  times  a  day  to  encourage  aeration  of  the 
posterior  parts  of  the  lungs.  It  is  of  the  greatest  importance  to  avoid 
overfeedmg,  or  anything  (including  many  of  the  time-honored  expec- 
torants) that  might  distm-b  the  appetite  and  the  digestion.  Food 
should  be  given  in  small  quantities  and  in  an  easily  digested  form. 
Xurslmgs  should  have  some  water  before  feedmgs,  and  the  intervals 
between  the  feedmgs  should  be  shortened,  and  for  the  bottle-fed  the 
milk  formula  should  be  reduced  in  strength.  Children,  between 
two  and  five  years  of  age,  with  poor  appetites,  are  given    albumin 


BRONCHOPNEUMONIA  429 

water,  whey,  meat  or  vegetable  broths,  expressed  beef  juice,  or  pep- 
tonized milk,  and  when  the  appetite  improves  diluted  milk,  gruels, 
light  puddings,  etc.,  may  be  added  to  the  list.  Under  all  circum- 
stances boiled  water  or  sweetened  lemonade  should  be  freely  offered 
and  the  bowels  kept  open  at  least  once  daily.  In  order  to  distiu-b 
the  patient  as  little  as  possible,  food,  medicine,  and  local  treatment 
should  be  given  at  one  time,  with  intervals  of  two  and  a  half  hours  of 
complete  rest.  Of  all  the  various  remedies  used,  the  most  important 
are  baths,  counterirritants,  stimulants,  and  inhalations  of  oxygen, 
and  of  moistened  air.  The  oiled  silk  and  cotton  jacket  seems  super- 
fluous. Although  the  old  method  of  using  the  tent  and  the  croup-kettle 
may  have  been  overdone  at  times,  for  there  is  no  doubt  that  a  con- 
tinuously moist  atmosphere  has  a  depressing  influence,  still,  when 
judiciously  used  (10  drops  of  creosote  added  to  1  quart  of  water)  for 
about  thirty  minutes  every  three  or  four  hours,  it  certainly  relieves 
the  acute  symptoms,  especially  the  irritating  cough  and  the  bronchial 
or  the  laryngeal  spasm. 

Counterirritation  over  the  chest  is  useful  in  relieving  pulmonary 
congestion  and  marked  bronchial  catarrh  by  causing  depletion  into 
the  peripheral  bloodvessels.  For  this  purpose  the  mustard  paste 
applied  over  the  chest  or  the  mustard  bath,  both  contmued  until  the 
skin  is  thoroughly  reddened,  are  equally  useful,  but  a  mustard  pack 
is  more  lasting  in  its  effects.  This  consists  of  steeping  a  cloth  in  one 
quart  of  water  (105°  F.)  containing  1  ounce  of  mustard  flour,  wTinging 
it  out  and  wrapping  it  snugly  around  the  patient  so  as  to  cover  the 
entire  skin  surface  except  the  head  and  the  neck.  A  woolen  blanket 
serves  as  an  outer  covering  and  is  so  adjusted  around  the  neck  that 
the  irritant  vapors  of  the  mustard  oil  are  not  inhaled  by  the  patient. 
As  soon  as  the  skin  is  thoroughly  reddened — after  ten  to  thirty 
minutes — the  child  should  be  washed  with  plain  warm  water  and  put 
into  a  moist  pack  for  one  to  two  hours  and,  finally,  given  a  cold 
sponge.  In  this  way  the  hyperemia  of  the  skin  is  kept  up  for  a  long 
time  afterward.  The  present-day  more  intelligent  use  of  hydrotherapy 
yields  good  results,  especially  when  given  w^ith  as  little  disturbance 
to  the  patient  as  possible.  Sponging  with  cool  water,  followed  by 
light  friction  with  a  dry  towel,  or  a  chest  compress,  the  water  used 
being  at  room  temperature  (70°  F.,  or  less,  for  "older  children),  and 
renewed  every  one  to  two  hours,  is  always  agreeable  to  a  fever  patient. 

For  infants  and  delicate  children  we  prefer  to  induce  deep  respha- 
tions  by  applying  warm  compresses  to  the  chest  followed  by  a  very 
short  application  of  cool  w^ater.  A  similar  effect  can  be  obtained  h\ 
spraying  a  little  cool  water  on  the  shoulders  and  the  back  of  the 
patient  durmg  a  warm  bath  (93°  to  95°  F.).  Hot  baths  (100°  to  104° 
F.),  even  in  the  presence  of  fever,  but  more  especially  with  cyanosis 
and  a  cold  skin  and  feeble  pulse,  are  valuable  in  quieting  the  patient 
by  reducing  pulmonary  congestion  and  equalizing  the  general  circula- 
tion. The  use  of  drugs  cannot  be  justified  unless  clearly  indicated 
for  the  relief  of  severe  symptoms;  they  are  directly  injurious  if  they 


430  DISEASES  OF   THE  RESPIRATORY   TRACT 

upset  digestion.  Usually  the  temperature  does  not  ruii  so  high  as  to 
require  special  treatment,  but  in  exceptional  cases  where  it  rises  above 
105°  F.,  hydrotherapeutic  measm'es  prove  superior  to  quinine  and  the 
coal-tar  products;  if  used  at  all  the  latter  should  only  be  employed 
to  allay  irritation  and  restlessness. 

Inlialations  of  steam,  as  in  bronchitis,  for  ten  to  fifteen  minutes  at 
a  time,  hot  drinks,  etc.,  promote  secretion  and  relieve  the  cough; 
but  when  the  latter  is  painful  or  incessant  a  sedative  will  be  required 
in  order  to  secure  sleep  and  to  avoid  any  unnecessary  strain  on  the 
heart.  We  recommend  codeine,  ^V  gr.,  or  morphine,  ^  gr.,  or  a  Dover's 
powder  1  gr.,  every  three  or  four  hours,  for  a  child  over  one  year  of 
age.  When  the  secretion  grows  excessive,  it  seems  better  to  check  it 
by  administering  five  to  ten  drops  of  belladonna  than  to  try  to  get 
rid  of  it  by  emetics.  Sooner  or  later  the  heart  suffers  from  the  pul- 
monary obstruction,  as  well  as  from  the  prolonged  fever  and  the 
general  toxemia,  and  should  be  stimulated  as  soon  as  a  very  rapid  or 
a  soft,  irregular  pulse  shows  that  such  assistance  is  needed.  Tincture 
of  strophanthus  retards  the  pulse,  while  strychnine  is  indicated  with 
an  irregular,  soft,  compressible  pulse;  both  are  useful  drugs  because 
they  are  easily  digested.  Caffein,  or  a  10  per  cent,  solution  of  cam- 
phorated oil,  or  a  ytwo  solution  of  adrenalin  in  5-  to  10-minim  doses, 
intramuscular h',  is  especially  valuable  for  h^'podermic  medication, 
in  spite  of  the  evanescent  effect,  ^^^lile  the  use  of  alcohol  has  been 
abused  in  bronchopneumonia,  it  is  sometimes  serviceable  when  all 
other  means  fail,  and  should  be  kept  in  reserve  for  such  emergencies. 
The  milder  stimulants  such  as  broth,  beef -tea,  tea,  or  coffee  mixed  with 
milk  can  be  given  quite  early  and  may  suffice  in  the  less  severe  cases. 
^Marked  cyanosis  is  temporarily  relieved  by  inhalations  of  oxygen, 
which  may  be  combmed  with  menthol,  turpentine,  or  bubbled  tlnough 
alcohol.  Atropine,  yfo"  of  ^  grain,  administered  hypodermically,  every 
four  hom's  to  a  child  of  three  years,  is  useful  when  the  dyspnea  and  the 
rapid  respu'ation  are  due  to  toxic  influences  on  the  respiratory  centre. 

Convalescence. — Convalescence  is  often  slow.  Open-air  treatment 
should  be  kept  up  during  the  warm  months.  If  the  catarrh  does  not 
fully  clear  up,  a  stay  in  the  country,  or  removal  to  a  warmer  climate 
during  the  wmter  is  usualh'  of  great  benefit.  Where  these  privileges 
cannot  be  enjoyed,  u'on,  arsenic,  quinme,  or  malt  extract  with  cod-liver 
oil  should  be  given  as  required. 


DISEASES   OF  THE  PLEURA. 

PLEURISY— SEROUS    AND   PURULENT. 

Inflammation  of  the  pleura  occurs  in  children,  as  in  adults,  either  in 
the  dry,  fibrinous  form  or  with  an  eft'usion  which  ma>'  be  either  sero- 
fibrinous  or   purulent    (empyema).      Of   these   the   purulent    variety 


PLEURISY  431 

demands  our  special  interest  because  of  its  comparative  frequency 
in  children,  especially  those  under  five  years  of  age,  and  because  it 
may  lead  to  a  fatal  issue  unless  prompt  diagnosis — by  no  means  always 
easy — points  the  way  for  proper  treatment. 

Although  pleurisy  may  be  caused  by  an  inflammation  spreading 
from  the  ribs,  the  vertebrae,  and  the  peritoneum,  it  is  not  merely  a 
local  affection  but  is  almost  always  a  sign  of  a  general  morbid  state. 
In  the  rare  examples  in  which  it  apparently  results  from  a  chill  or  from 
exposure,  it  is,  no  doubt,  really  tuberculous  or  rheumatic  in  origin. 
It  has  been  observed  in  sepsis  of  the  newborn,  during  and  following 
the  infectious  fevers,  such  as  scarlet  fever,  measles,  grippe,  whooping- 
cough,  diphtheria,  and  typhoid  fever,  but  the  majority  of  all  cases 
occur  secondarily  to  pneumonia  and  bronchopneumonia.  For  this 
reason  it  prevails  more  often  during  the  cold,  damp  season,  and  is 
more  apt  to  affect  boys  than  girls  on  account  of  their  greater  liability 
to  contract  pneumonia.  Pleurisy  is  not  frequent  in  infants  less  than 
six  months  old,  but  is  quite  common  between  the  sixth  month  and 
the  sixth  year,  and,  as  a  rule,  the  younger  the  patient  the  greater  the 
likelihood  of  its  being  purulent  in  character. 

Pathological  Anatomy. — Postmortem  the  pleura  may  merely  show  a 
lack  of  luster,  some  adhesions  either  localized  or  spreading  over  more 
or  less  extensive  areas,  and  deposits  of  fibrin  varying  from  simple 
roughening  to  a  felt-like  layer  sometimes  |  to  1  inch  thick.  In  these 
extreme  cases,  a  shrinking  of  the  lung  and  a  corresponding  retraction 
of  the  affected  side  naturally  follow.  The  effusions  differ  greatly  in 
quantitv  and  also  in  character  in  different  cases;  they  may  be  unilat- 
eral, bilateral,  or  sacculated,  i.  e.,  localized,  and  shut  off  from  the  rest 
of  the  pleural  cavity  by  adhesions.  A  large  amount  of  fluid  in  the 
pleural  cavity  will  push  the  lung  upward,  thus  assisting  its  natural 
tendency  to  recoil  and  allowing  very  little  possibility  for  expansion. 
A  serous  effusion  has  a  light  greenish-yellow  color ;  it  is  clear,  or  slightly 
cloudy,  and  contains  fibrinous  shreds;  in  favorable  circumstances, 
it  is  capable  of  being  completely  absorbed  with  little  diminution  of 
the  respiratory  capacity.  Large  purulent  effusions,  however,  are  not 
absorbed,  and  an  empyema  if  not  properly  treated  results  in  pyemia 
or  cachexia,  unless  the  pus  finds  a  natural  outlet  by  ulcerating  through 
the  thoracic  wall,  or  by  breaking  into  a  bronchus.  While  it  is  true 
that  a  serous  effusion  may  exceptionally  become  purulent  by  second- 
ary infection,  an  acute  pleuritis,  as  a  rule,  must  necessarily  be  either 
serous  or  purulent,  according  to  the  predominating  microorganism. 
Generally  speaking,  a  thin,  yellowish  pus  indicates  a  streptococcic 
infection  and  a  thick,  pale  green  discharge  a  pneumococcic  infection, 
though,  of  course,  the  naked  eye  appearances  are  not  very  reliable. 
The  consistency  depends  upon  the  relative  proportion  of  serum  and 
pus  cells  present. 

Bacteriology. — In  pleuiisy,  pneumococci  are  usually  present;  strep- 
tococci and  staphylococci  are  less  frequent,  while  typhoid,  colon,  and 
influenza  bacilli  are  only  occasionally  found.    Empyema,  in  70  to  90 


432  DISEASES  OF   THE  RESPIRATORY  TRACT 

per  cent,  of  cases  is  due  to  pneumococci,  either  in  pure  culture,  or 
combined  with  other  microorganisms;  streptococci  predominate  in 
5  to  15  per  cent.,  while  tubercle  bacilli  are  responsible  for  only  about 
5  per  cent,  of  all  cases  of  empyema  in  children. 

The  amount  of  fluid  varies  according  to  the  age  and  the  size  of  the 
child  and  the  duration  as  well  as  the  character  of  the  effusion;  it  is 
greater  when  the  fluid  is  thin.  In  children  under  three  }'ears  it  rarely 
amounts  to  more  than  |  to  1  pint  while  in  older  patients  as  much  as 
3  or  4  pints  is  not  uncommon. 

Symptoms. — These  vary  considerably  in  the  different  types  of 
pleurisy.  In  a  well-marked  case,  more  or  less  fever,  cough,  and  pain, 
together  with  respiratory  and  circulatory  disturbances,  are  present, 
and  are  not  infrequently  accompanied  by  headache,  vomiting,  and 
constipation.  Generally  speakmg,  a  baby  sick  with  pleurisy  is  very 
sick  indeed  and  looks  it.  As  mentioned  before,  most  cases  occur 
secondarily  to  pneumonia  or  to  bronchopneumonia,  either  during 
their  course,  thereby  greatly  prolongmg  the  duration  of  the  fever, 
or — more  commonly — within  a  few  days  after  the  crisis  or  the  lysis. 
In  these  cases  the  onset  is  marked  by  a  new  rise  of  temperature  up 
to  103°  or  104°  F.,  an  aggravation  of  the  dyspnea,  and  the  cough, 
often  also  of  the  pain,  and  a  pronounced  mcrease  in  the  pulse  rate. 
A  sudden  onset,  somewhat  resembling  that  of  a  milder  pneumonia, 
characterizes  these  comparatively  rare  cases  of  primary  pleurisy, 
which  begin  with  headache,  vomiting,  chills  and  fever,  102°  to  103° 
F.,  and  are  soon  followed  by  a  hacking  cough,  pain  in  the  chest,  and 
shallow,  rapid  breathing.  Occasionally  the  onset  is  more  lingering 
or  gradual  m  type.  The  child  is  ailing  for  a  week  or  two,  with  failing 
appetite  and  a  low  fever,  increasing  weakness,  anemia,  and  a  slight 
cough. 

AMien  the  pleuritic  effusion  has  taken  place,  the  clinical  picture 
changes,  the  symptoms  naturally  \'arymg  with  the  amount  of  fluid 
and  the  rapidity  of  its  accumulation.  The  patient  often  lies  on  the 
affected  side,  avoids  loud  crying,  is  pallid,  as  a  rule,  but  becomes 
cyanotic  when  the  heart  is  embarrassed  by  the  fluid.  The  cough  may 
disappear,  though  sometimes  it  becomes  spasmodic.  Breathing  is  rapid, 
superficial,  and  increased  on  the  sound  side,  while  the  dyspnea  becomes 
very  apparent  on  the  least  exertion  in  speaking  or  moving.  Often 
there  is  neither  pain  nor  cough  to  indicate  the  seat  of  the  trouble; 
such  cases  of  malaise,  feverishness,  accompanied  by  poor  appetite, 
coated  tongue  and  restlessness  are  quite  likely  to  be  designated 
"dentition  fever." 

Fever. 

Pain. 

Cough. 

Respiration:  dyspnea. 

Circulation:  cyanosis. 

Fever . — Too  much  reliance  should  not  be  placed  on  the  temperature 
charts,  as  the  fever  often  runs  an  irregular  and  exceedingly  variable 


Individual  symptoms 


PLEURISY  .  433 

course.  It  is  usually  high  durmg  the  first  few  days,"  ranging  between 
101°,  104°,  or  105°  F.,  and  in  serofibrinous  effusion  is  apt  to  become 
remittent;  during  the  second  or  third  week  it  abates  as  the  absorp- 
tion of  the  fluid  progresses.  In  empyema,  the  temperature  rise  is 
usually  not  quite  so  high  at  first,  it  may  be  irregular,  intermittent, 
or  hectic,  with  night-sweats  and  rapid  emaciation,  especially  when 
following  the  exanthemata.  In  a  pneumococcic  pleuritis,  the  tem- 
perature variations  do  not  seem  so  marked.  Unless  properly  treated, 
the  fever  may  last  many  weeks;  but,  on  the  other  hand,  it  may  be 
entirely  absent  in  the  later  stage. 

Pain. — Pain  in  the  side,  aggravated  by  deep  breathing  and  coughing 
and  not  infrequently  referred  to  the  abdomen  or  the  shoulder,  is  an 
early  symptom,  and  usually  disappears  with  an  effusion  sufficient  to 
separate  the  pleural  surfaces.  The  aft'ected  side  may  be  tender  to 
pressure;  pain  in  the  right  side  is  due  to  pressure  of  a  right-sided 
effusion  on  the  liver. 

The  Cough. — The  short,  dry,  painful  cough,  which  the  child  makes 
every  effort  to  suppress,  may  become  less  frequent  and  may  some- 
times, but  not  always,  disappear  when  the  eft'usion  is  large. 

Respirations. — Respirations  are  frequent,  shallow,  often  irregular, 
and  more  or  less  painful,  especially  in  diaphragmatic  pleurisy.  Often 
the  child  lies  on  the  affected  side  in  order  to  limit  its  movements 
and  allow  more  freedom  of  expansion  to  the  sound  lung.  The  pain 
usually  diminishes  as  the  extravasation  increases,  but  the  shortness 
of  breath  (dyspnea)  becomes  more  noticeable  the  more  the  lung 
recoils  (favored  by  mechanical  compression).  When  the  effusion 
advances  rapidly,  the  distress  is  very  marked  indeed,  while  it  may 
escape  attention  when  its  progress  is  slow.  In  empyema  the  respira- 
tions are  always  increased  to  40  to  70  per  minute.  The  dyspnea 
corresponds  to  the  amount  of  fluid,  but  often  manifests  itself  only  on 
exertion  or  by  a  feeling  of  fatigue. 

The  Circulation. — The  pulse  is  always  rapid,  100  to  150  per  minute, 
even  where  there  is  little  or  no  fever;  it  becomes  still  more  accelerated 
during  the  febrile  period,  or  when  a  large  or  rapidly  increasing  effusion 
embarrasses  the  heart.  It  then  becomes  feeble,  irregular,  and  very 
rapid  upon  the  slightest  exertion.  In  addition,  venous  engorgement 
of  the  face  and  the  neck  may  become  noticeable.  All  cases  of  pleural 
eft'usion  lead  to  a  more  or  less  pronounced  anemia;  empyema,  further- 
more, is  usually  attended  with  loss  of  flesh  and  prostration,  sometimes 
with  night-sweats,  and,  in  more  chronic  cases,  a  rapidly  developing 
clubbing  of  the  fingers  accompanied,  not  with  cyanosis,  but  with  a 
peculiar  yellowish  tint  of  the  skin. 

The  Course. — Dry  pleurisy  clears  up  within  a  week,  unless  due  to 
tuberculosis  or  to  pneumonia.  Very  large  effusions  may  cause  cyanosis, 
pulmonary  edema,  and  death  if  not  relieved  in  time.  The  acute  stage 
of  empyema,  with  loss  of  appetite,  flesh,  and  strength,  and  sometimes 
accompanied  by  hectic  fever  and  night-sweats,  lasts  about  two  to 
four  weeks.  It  may  be  followed  by  apparent  convalescence,  durmg 
28  '      . 


434  DISEASES  OF  THE  RESPIRATORY  TRACT 

which  the  patient  has  Httle  or  no  fever  and  seems  to  be  regaining  his 
color  and  strength,  but  the  cough  and  the  rapid  respiration  and  the 
dyspnea  reappear  on  the  sHghtest  provocation  and  give  fair  warning 
of  a  false  security.  If  empyema  is  allowed  to  become  chronic  the 
sjTQptoms  resemble  those  of  tuberculosis. 

Physical  Signs. — The  chest  signs  are  essentially  the  same  whether 
caused  by  a  serous  or  by  a  purulent  effusion.  While  an  appreciable 
amount  of  free  fluid  in  the  plem-al  cavity  of  one  side  is  quite  easily 
detected,  detection  is  more  difficult  w^hen  the  effusion  is  localized  or 
bilateral,  or  w^hen  there  has  been  a  previous  thickenmg  of  the  pleura. 
The  upper  border  of  the  lung,  as  a  rule,  remains  unchanged,  but  the 
lower  resonant  border,  retracting  from  the  gradually  increasing  fluid, 
is  highest  in  the  axilla,  sloping  downward  and  inward  to  the  sternum 
in  front  and  toward  the  spine  posteriorly.  The  lower  limit  of  the  fluid 
is  not  identical  with  the  lower  border  of  the  normal  lung  because 
the  diaphragm  is  often  elevated  even  with  a  comparatively  large 
effusion,  and  becomes  depressed  only  in  the  late  stage  when  extravasa- 
tion is  excessive. 

Inspection. — In  addition  to  the  shallow,  accelerated,  jerky,  and 
painful  breathing  in  effusion  of  appreciable  degree,  the  affected  side 
appears  larger,  the  respiratory  excursions  are  diminished  and  the 
depression  of  the  intercostal  spaces  is  less  noticeable. 

In  a  very  marked  effusion  the  signs  of  severe  dyspnea,  of  expiratory 
distention  of  the  large  veins  of  the  neck,  the  increased  measurement 
of  the  affected  side,  the  displacement  of  the  heart,  and  possibly  an 
elevation  of  the  shoulder,  are  so  obvious  as  hardly  to  be  overlooked. 

Palpation. — Vocal  fremitus,  quite  apart  from  the  fact  that  it  is 
not  easily  elicited  in  young  children,  is  lost  or  lessened  over  the  fluid; 
respiratory  movements  are  diminished  over  the  affected  side  and 
increased  over  the  sound  one.  There  may  be  sensitiveness  to  pressure 
between  the  ribs.  With  a  large  left-sided  effusion  the  apex  beat  may 
be  palpable  at  the  epigastrium  or  even  further  to  the  right,  but  in  a 
right-sided  effusion  the  apex  may  be  found  displaced  to  the  left  as  far 
as  the  midaxillary  line. 

Percussion. — Percussion  is  often  painful  over  the  affected  pleura, 
and  often  gives  much  more  valuable  mformation  than  auscultation. 
It  should  be  done  lightly  as,  otherwise,  a  thin  layer  of  fluid  over  the 
spongy  lung  tissue  or  over  the  stomach  would  cause  no  appreciable 
impairment  of  the  note.  With  the  child  in  an  upright  sitting  posture 
a  dull  rather  than  a  flat  note  is  elicited  over  the  fluid,  which  commonly 
gathers  in  the  lower  and  posterior  part  of  the  chest,  and  when  encap- 
sulated occasionallv  in  other  parts  of  the  ches^".  Owing  to  the  gravita- 
tion of  the  fluid,  the  upper  line  of  dulness  often  shifts  with  a  change  of 
position;  resonance  amounting  to  subclavicular  tympany  iu  verv 
large  effusions  is  always  found  directl.y  above  the  fluid.  When  the 
latter  almost  fills  the  entire  side,  the  dulness  may  extend  beyOnd  its 
border  some  distance  to  the  sound  side — beyond  the  sternum  anteriorly 
and  the  spine  posteriorly. 


PLEURISY  435 

A  very  valuable  sign  appreciated  by  the  percussion  finger  is  a  peculiar 
board-like  resistance,  doubly  striking  in  children  on  account  of  their 
naturally  thin  and  elastic  chest  walls.  Displacement  of  the  liver 
downward  encroaching  upon  the  stomach,  but  especially  on  the  heart, 
as  mentioned  under  palpation,  is  almost  pathognomonic.  Dulness 
on  percussion  and  a  board-like  resistance  are  alone  sufficient  to  justify 
exploratory  puncture  in  order  to  determine  the  character  of  the  sus- 
pected pleural  effusion. 

Auscultation. — As  a  whole,  auscultatory  findings  are  very  variable, 
and  therefore  unsatisfactory  and  even  misleading  in  infants  and  chil- 
dren. Early  in  pleurisy,  and  again  when  the  fluid  is  almost  absorbed, 
a  friction  rub  may  perhaps  be  heard  with  inspiration  or  expiration  or 
with  both;  it  is  superficial  in  character  and  unchanged  by  coughing. 
Only  in  rare  cases  where  a  large  effusion  leads  to  compression  of  the 
lungs  is  there  sometimes  complete  absence  of  voice  and  respiratory 
sounds.  They  frequently  remain  almost  normal  but  are  usually  dimin- 
ished, distant,  and  indistinct.  Bronchial  breathing,  although  usually 
more  feeble  and  distant  over  the  fluid  on  deep  breathing,  is  sometimes 
as  marked  as  it  is  in  pneumonia.  It  is  often  heard  also  along  the 
spine  and  the  sternum — an  important  fact  in  differentiating  the 
condition  from  pneumonia.  Whatever  the  character  of  the  breath 
sounds  on  the  affected  side  they  contrast  markedly  with  those  of  the 
healthy  lung  where  they  are  puerile  and  harsh  (exaggerated) . 

X-rays  are  helpful  in  locating  sacculated  empyemas;  in  a  general 
effusion  they  show  the  diminished  movement  of  the  pleura  on  the 
affected  side  and  the  displacement  of  various  organs.  In  the  interest 
of  exact  diagnosis  and  prognosis  an  exploratory  puncture  is  advisable, 
even  though  there  may  be  bronchial  breath  sounds  or  crepitations 
audible  over  the  area  of  increasing  dulness.  The  point  of  choice  for 
the  puncture  is  the  posterior  axillary  line — the  sixth  interspace  on  the, 
left  side,  the  flfth  on  the  right  side.  When  the  fluid  is  localized  the 
puncture  should  be  made  over  the  point  of  most  marked  impaired 
resonance.  With  the  proper  antiseptic  precautions,  a  sterile  needle 
is  introduced  slowly  for  about  an  inch,  gentle  suction  being  kept  up 
all  the  time.  If  the  needle  becomes  plugged  up  on  account  of  its  small 
calibre,  it  may  happen  that  no  pus  can  be  obtained;  this  may  also 
occur  if  the  needle  is  pushed  beyond  the  visceral  pleural  layer  into 
the  lung  tissue,  or  if  it  penetrates  an  adhesion,  or  a  mass  of  fibrin,  etc. 
The  fluid  when  obtained  should  be  submitted  to  a  bacteriological 
examination. 

Differential  Diagnosis. — The  diagnosis  of  pleinal  eft'usion  m  the 
presence  of  dulness  or  flatness,  and  of  more  or  less  displacement  of  the 
heart  or  the  liver,  is  definitely  determined  by  exploratory^  puncture. 
This  makes  it  possible  to  exclude  allied  conditions,  such  as  unresolved 
pneumonia,  pulmonary  tuberculosis  with  extensive  caseation,  and 
the  rare  cases  of  abscess  of  the  lung.  The  differentiation  is  more 
difficult  in  case  of  subphrenic  abscess,  of  large  pericardial  effusions,  and 
of  localized  empyema.  Again,  typhoid  fever  and  malaria  may  simulate 


436  DISEASES  OF   THE  RESPIRATORY   TRACT 

the  constitutional  symptoms  of  empyema,  but  the  different  physical 
findings  and  the  blood  examination  hardly  leave  room  for  doubt. 

Prognosis. — Spontaneous  recovery  of  empyema  cannot  be  expected, 
although  Nature  does  make  an  attempt  to  get  rid  of  the  effusion.  The 
pus  may  break  through  into  a  bronchus  and  be  coughed  up,  thus 
giving  some  temporary  relief;  or  it  may  be  directed  externally  and 
continue  to  discharge  for  many  months,  the  patient  finally  dying 
from  exhaustion,  amyloid  degeneration,  or  tuberculosis.  In  the 
absence  of  serious  complications,  such  as  double  empyema,  purulent 
pericarditis,  meningitis,  pyemia,  or  pulmonary  tuberculosis,  prompt 
and  efficient  treatment  is  certainly  very  satisfactory;  but  the  final 
outcome  will  naturally  depend  upon  several  other  factors.  The  disease 
is  very  grave  and  the  mortality  is  high,  especially  in  hospital  children 
under  one  year  of  age.  After  the  second  year  the  prognosis  is  very 
good,  for  with  early  surgical  treatment  recovery  is  almost  the  general 
rule.  A  delayed  operation  cannot  give  as  good  results  on  account 
of  the  greater  weakness  of  the  patient  and  the  increasing  difficulty 
of  proper  reexpansion  of  the  lung.  In  general,  the  outlook  is  best 
when  the  disease  is  of  pneumococcic  origin,  less  so  when  staphylococcic, 
worst  of  all  when  streptococcic. 

Treatment. — Fresh  air,  simshme,  avoidance  of  all  exertion,  are  as 
essential  here  as  in  pneumonia.  Fixation  of  the  affected  side  by 
flannel  bandages  and  the  application  of  heat  in  the  form  of  fomen- 
tations or  turpentine  stupes,  or  of  mustard  paste,  usually  suffice  for 
the  relief  of  pain.  However,  sometimes  opiates  (codeine,  morphine,  or 
paregoric)  are  necessary  to  prevent  loss  of  sleep  from  excessive 
coughing. 

During  the  febrile  stage,  dry  and  serofibrinous  pleurisy  are  treated 
alike  by  a  fever  diet  and  rest  in  bed.  As  soon  as  there  is  a  tempera- 
ture or  there  are  signs  of  an  effusion,  the  child  must  neither  sit  up  nor 
exercise  its  arms  and  its  lungs  more  than  is  absolutely  necessary. 
When  a  serous  effusion  has  occurred,  the  diet  adapted  to  the  dimin- 
ished digestive  capacity  is  (for  children  over  two  years  of  age)  usually 
restricted  principally  to  solids — bread  and  butter,  eggs,  puddings, 
beef-juice,  malt  extracts,  and  very  little  milk;  although  it  is  very 
doubtful  whether  a  diminution  of  liquids  influences  the  absorption 
of  the  fluid.  This  may  be  facilitated  to  some  extent  by  external  appli- 
cations of  heat,  counter-irritants,  ointments  containing  10  to  16  per 
cent,  of  guaiacol,  hydrargyrum  or  iodine,  and  by  purgatives  and  diu- 
retics. It  is  always  wise  to  prescribe  some  heart  stimulant,  either 
digitalis  or  strophanthus.  Sodium  salicylate,  or  aspirin  (5  grains  4 
times  a  day)  in  sugar  water,  is  best  given  in  the  early  stage,  and 
potassium  iodide  later  on  when  absorption  has  begun. 

Evacuation  of  the  effusions  during  the  acute  stage  is  contraindi- 
cated,  except  when  breathlessness,  cyanosis,  and  cardiac  embarrass- 
ment make  it  imperative;  but  if  the  fluid  does  not  diminish  within 
two  to  three  weeks  it  should  be  removed  (except  in  tuberculosis)  by 
siphonage  or  aspiration.     Drainage  can  be  secured  either  by  simple 


PLEURISY  437 

incision  after  the  site  of  tlie  pus  has  been  ex]>lore(l  with  the  needle  or 
by  resection  of  a  portion  of  one  or  of  several  ribs.  Simple  incision 
is  more  quickly  done.  It  requires  only  local  anesthesia  and  usually 
proves  successful,  especially  in  babies  under  two  years  old.  An 
incision  about  two  inches  long  is  made  in  the  fifth  or  sixth  interspace 
in  the  middle  axillary  line,  close  to  the  lower  rib  through  the  inter- 
costal muscles.  After  opening  the  pleura,  the  pus  is  allowed  to  escape 
slowly,  large  coagula  being  removed  w^ith  forceps,  and  a  short  drainage 
tube  of  large  calibre  (or  two  smaller  ones  side  by  side  if  the  ribs  are 
close  together)  is  inserted  and  fastened  with  large  safety  pins.  The 
whole  is  covered  by  a  thick  aseptic  dressing  which  must  be  renewed 
or  reinforced  when  it  becomes  saturated.  The  drainage  tube  should 
be  removed  as  soon  as  the  discharge  grows  serous.  The  wound  then 
closes  in  a  short  time,  and  is  usually  completely  healed  within  three  to 
seven  weeks  after  operation. 

Resection  of  a  part  of  one  or  of  several  ribs  is  the  best  means  of 
ensuring  thorough  evacuation  and  also  rapid  recovery.  Only  light, 
general  narcosis  is  necessary.  An  incision,  two  to  three  inches  long, 
is  made  directly  over  the  eighth  or  ninth  rib,  in  the  posterior  axillary 
line;  the  periosteum  being  stripped  back,  about  two  inches  of  the  rib 
are  cut  away  with  bone  forceps  or  with  special  rib-shears.  On  open- 
ing the  pleura,  pus  flows  out  with  each  respiration,  and  more  rapidly 
with  coughing.  Some  surgeons  insert  the  finger  to  remove  thick  masses, 
or  break  down  adhesions  in  order  to  empty  any  existing  pockets  of 
pus,  and  even  advise  irrigation  of  the  pleura  with  saline  solution. 
However,  it  is  not  necessary  to  empty  the  cavity  completely,  for  what 
remains  is  often  rapidly  absorbed,  but  it  is  essential  that  the  with- 
drawal should  be  gradual,  and  that  it  be  stopped  with  the  appearance 
of  violent  coughing,  w^eakness,  fainting,  or  bleeding. 

If  the  effusion  were  allowed  to  stay  from  six  to  eight  weeks,  thicken- 
ing of  the  pleura,  adhesions,  and  impeded  expansion  of  the  lungs  would 
probably  result.  Therefore,  w^hen  repeated  tapping  in  serous  effusions 
effects  no  cure,  incision  and  drainage  become  necessary.  The  point 
of  choice  for  paracentesis  is  in  the  sixth  or  seventh  interspace  near  the 
middle  or  posterior  axillary  line  or  at  the  place  of  greatest  flatness. 
If  there  is  any  uncertainty  as  to  the  exact  site  of  the  fluid,  this  should 
be  ascertained  by  puncture.  With  the  proper  antiseptic  precautions 
and  with  the  child  in  a  sitting  posture,  a  trocar  of  y^-inch  calibre  is 
quickly  introduced  for  about  an  inch  close  to  the  upper  edge  of  the 
rib.  While  an  effusion  of  recent  date  evacuates  itself,  unless  fibrin 
shreds  obstruct  the  opening,  very  little  or  nothing  at  all  will  flow  out 
spontaneously  in  a  chronic  case  on  account  of  the  insufficient  pressure, 
and  removal  by  siphon  or  aspiration  may  become  necessary.  The 
small  opening  is  subsequently  closed  with  collodion. 

The  fluid  in  young  children  is  usually  purulent  or  seropurulent. 
The  only  satisfactory  treatment  for  this  is  surgical  evacuation  of  the 
pus  as  soon  as  diagnosis  has  been  made.  A  short  delay  may  be  per- 
missible only  in  a  small  empyema  following  pneumonia  when  con- 


438  DISEASES  OF   THE  RESPIRATORY   TRACT 

valescence  is  otherwise  satisfactory.  Aspiration  is  insufficient  except 
as  a  temporary  measure  to  relieve  distress,  and  as  a  preliminary  reduc- 
tion of  excessive  effusion. 

Dm'ing  convalescence  the  patient  should  li\'e  in  the  open  air  but 
should  avoid  any  excessive  use  of  the  chest  and  the  arms.  The  diet 
should  be  carefully  regulated,  and  malt  extract  with  iron,  cod-liver 
oil,  and  arsenic  administered  in  proper  moderation.  Later,  breathing 
exercises,  varied  so  as  to  take  the  fancy  of  the  child,  such  as  blowmg 
a  trumpet,  or  soap-bubbles,  or  fluids  from  one  bottle  to  another,  are 
advisable  as  aids  in  successfully  reestablishmg  the  expansion  of  the 
chest.  After  six  months  the  orthopedic  surgeon  should  be  consulted 
for  any  chest  and  spinal  deformity,  although  breathing  and  gym- 
nastic exercises  properly  directed  and  intelligently  carried  out  may  do 
much  to  diminish  such  deformities. 

Bilateral  empyema  is  rare.  If  general,  on  both  sides,  it  is  wise  to 
relieve  strain  on  the  heart  by  preliminary  aspiration  followed  in  a  day 
or  two  by  draining  the  left,  and  later  the  right  side.  In  chi-onic 
empyema  more  extensive  operations,  such  as  advised  by  Estlander 
Schedes,  may  become  necessary,  or  even  decortication  of  the  thickened 
visceral  pleura  may  have  to  be  resorted  to.  Summing  up,  one  would 
say  that  for  the  successful  management  of  empyema  it  is  essential 
to  diagnose  it  early,  to  establish  prompt  and  efficient  drainage,  and 
to  pay  particular  attention  to  the  after  treatment.  Failure  is  due  to 
either  delay,  to  thick  adhesions,  to  mefficient  drainage,  or  to  the 
formation  of  a  persistent  sinus. 

REFLEX   COUGH. 

A  cough,  strictly  speaking,  is  always  reflex  in  origin;  but,  for  the 
sake  of  convenience,  we  will  group  mider  this  heading  all  those  clmical 
varieties  of  cough  which,  because  they  furnish  no  obvious  sign  of 
inflammation  of  the  lar^Tix,  trachea,  bronchi,  lungs,  or  pleura,  are 
supposed  to  be  due  either  to  vague  stimulation  m  the  mouth,  throat, 
stomach,  or  ear,  or  to  irritation  of  other  organs.  It  is  not  an  aftec- 
tion  of  early  infancy,  but  quite  frequently  attacks  older  children. 
Cough  is  most  common  in  that  form  of  postnasal  catarrh  which  is 
associated  with  enlarged  tonsils  and  adenoids.  ^lucus  or  mucopus 
accumulations  m  the  nasopharynx  excite  a  dry,  tickling  cough  which 
usually  comes  on  as  soon  as  the  child  lies  down  (and  sometimes  only 
then),  and  is  thus  apt  to  disturb  the  sleep  for  hours.  It  may  last  for 
many  months,  especially  in  winter. 

Similar  symptoms  may  be  caused  by  an  elongated  uvula,  or  in  rare 
cases,  by  cerumen  impacted  in  the  external  auditory  meatus.  In 
mitral  disease,  probably  because  of  the  resultmg  pulmonary  congestion, 
and  in  pericarditis,  a  dry  hard  cough  often  makes  the  patient  very 
uncomfortable. 

About  the  time  of  puberty,  and  frequently  associated  with  anemia, 
chorea,  or  extreme  nervous  irritability,  a  cough  may  spring  up  which 


ASTHMA  439 

may  be  either  of  the  ordinary  type  or  a  curiously  monotonous  one; 
it  is  increased  by  exercise,  and  ceases  during  sleep.  There  is  neither 
pain,  nor  expectoration;  the  onset  and  the  termination  may  be  either 
gradual  or  sudden,  while  relapses  are  frequent. 

Periodic  attacks  of  a  brassy  cough  may  occur  regularly  every  night 
for  months,  the  paroxysms  sometimes  becoming  so  severe  as  to  resemble 
whooping-cough,  except  for  the  almost  complete  absence  of  vomiting. 
These  paroxysms  are  ascribed  to  an  irritation  of  the  pneumogastric 
nerve  or  its  branches,  due  to  the  pressure  of  enlarged  lymph  nodes 
surrounding  the  trachea  and  the  large  bronchi.  This  glandular 
enlargement  may  be  present  in  Hodgkin's  disease,  and  in  lymphatic 
leukemia,  or  it  may  follow  various  pulmonary  affections,  but  in  many 
cases  it  is  really  the  primary  focus  of  tuberculosis. 

The  patients  sometimes  seem  the  very  picture  of  health;  but  ordi- 
narily long-continued  loss  of  sleep  tells  on  the  general  health,  and 
when  the  enlargement  is  part  of  a  tuberculous  process  the  child  is 
apt  to  be  delicate,  irritable,  and  easily  fatigued,  while  the  appetite 
is  failing  or  capricious.  The  patient  complains  of  interscapular  back- 
ache, or  ill-defined  pain  within  the  thorax,  or  sharp  and  lancinating 
pain  brought  on  by  deep  inspiration  or  by  violent  exertion.  The 
superficial  thoracic  vems  may  be  dilated.  Usually  there  is  some 
expiratory  dyspnea,  and  not  infrequently  an  increased  sensitiveness 
to  cold,  especially  in  the  region  of  the  shoulder.  A  similar  cough  has 
been  observed  in  connection  with  abscesses  of  the  posterior  medias- 
tinum, and  in  Pott's  disease. 

Symptoms. — In  all  of  these  cases  it  is  chiefly  the  cough  which  excites 
concern.  This  grows  worse  or  occurs  only  at  night,  and  is  liable  to 
become  paroxysmal,  the  attacks  coming  on  rather  regularly.  The 
general  health  may  not  be  affected  except  for  the  distm-bed  sleep. 

Diagnosis. — A  reflex  cough  should  not  be  diagnosed  lightly.  By 
a  thorough  examination  of  the  ears,  the  nose,  and  the  throat,  as  well 
as  the  heart,  the  lungs,  and  the  stomach,  in  conjunction  with  careful 
observation  of  the  general  condition,  it  is  often  possible  to  ascertain 
its  precise  cause.  X-rays  are  of  great  service  in  cases  where  enlarged 
lymph  nodes  are  suspected,  as  after  measles,  pertussis,  repeated  attacks 
of  bronchitis,  or  in  patients  with  tubercular  antecedents. 

Treatment. — It  is  obvious  that  neither  opium,  nor  inhalations,  nor 
expectorants  will  effect  a  cure.  The  underlying  cause  must  be  treated. 
If  this  cannot  be  detected  and  the  condition  seems  purely  nervous, 
small  doses  of  the  bromides  and  of  antipyrin  may  be  given  at  bedtime 
to  relieve  the  cough. 

ASTHMA. 

Excluding  cases  of  mere  dyspnea  due  to  cardiac  or  renal  diseases, 
two  chief  types  of  asthma  are  met  with  in  children;  the  first,  the 
spasmodic  or  true  bronchial  variety,  resembles  that  of  adults,  and  is 
characterized  by  paroxysms  of  expiratory  difficulty,  the  respiratory 
system  remaining  apparently  normal  during  the  intervals.    It  is  only 


440  DISEASES  OF   THE  RESPIRATORY   TRACT 

exceptionally  observed  in  children  under  four  years  of  age,  but  seems 
not  so  luicommon  from  the  seventh  or  eighth  year  up  to  puberty. 
The  second,  the  catarrhal  type  or  so-called  asthmatic  bronchitis, 
differs  from  the  former  variety  in  the  increased  amount  of  bron- 
chial secretion  and  in  the  character  of  the  dyspnea,  the  paroxysms 
being  preceded,  associated,  or  followed  by  bronchitis.  It  is  not  quite 
so  rare  in  infants  as  the  first  type,  and  is  also  rather  commoner  in 
older  children.  They  may  suffer  from  one  or  several  attacks  during 
the  year,  and  are  liable  to  be  somewhat  short  of  breath  during  the 
intervals.  It  may  be  said,  in  passmg,  that  undoubted  cases  of  hay 
asthma,  occurring  especially  during  hot  and  protracted  summers,  have 
been  observed  as  early  as  the  fourth  year  in  children  of  neuro-arthritic 
families. 

Etiology. — The  pathogenesis  in  the  child  is  no  doubt  essentially 
the  same  as  in  the  adult;  that  is,  there  exists  a  neurosis  of  the  respira- 
tory system,  manifested  by  paroxysmal  spasms  of  the  respiratory 
muscles,  combined  with  hypersensitiveness,  temporary  vasomotor 
paresis,  and,  perhaps,  an  abnormal  secretion  of  the  respiratory  mucous 
membrane.  These  diverse  factors  probably  cause  a  temporary  nar- 
rowing of  the  lumen  of  the  bronchial  tubes.  Heredity  plays  an  impor- 
tant role,  there  being  usually  a  family  history  of  various  neuroses, 
gout,  eczema,  and  neuro-arthritis.  The  poorer  classes  are  relatively 
seldom  affected.  Dry  climates  yield  the  smallest  percentage  of  cases. 
When  an  attack  has  once  occurred,  other  paroxysms  are  readily  induced 
by  central  or  by  peripheral  reflexes.  While  psychic  factors,  such  as 
fright,  emotion,  and  excitement,  are  only  occasionally  responsible  for 
an  attack,  one  may  be  easily  induced  by  any  local  irritation  of  the 
nose,  the  pharynx,  or  the  bronchial  mucous  membrane,  due  to  inflam- 
mation caused  either  by  the  inhalation  of  irritants,  such  as  dust,  pollen, 
gases,  certain  animal  emanations,  or  to  sudden  changes  of  climate  or 
of  weather  conditions.  Furthermore,  disturbances  of  the  gastro- 
intestinal tract  and  enlarged  bronchial  glands  also  act  as  exciting 
factors  in  susceptible  children.  These  are  usually  delicate,  nervous, 
irritable,  and  anemic,  suffering  from  eczema,  from  chronic  urticaria, 
and  hypertrophy  of  the  tonsils  and  adenoids,  though  the  overfed 
child  is  by  no  means  exempt.  The  symptoms  of  spasmodic  or  true 
bronchial  asthma  in  children  do  not  differ  essentially  from  those  in 
adults.  There  is  a  periodic,  urgent,  and  usually  sudden  dyspnea. 
The  child,  apparently  well,  awakens  in  a  fright  a  few  hours  after 
retiring,  it  has  a  sense  of  impending  suffocation,  looks  anxious  and 
pale,  is  more  or  less  cyanotic,  restless  and  rigid,  or  sits  up  in  bed  with 
staring  eyes,  head  thrown  back,  shoulders  raised,  and  its  little  hands 
clinched,  to  all  appearances  fighting  against  a  distressing  dyspnea. 

The  breathing  is  slow  and  labored,  the  shallow  inspirations  are  fol- 
lowed by  a  pause  and  prolonged  expirations,  while  both  are  accom- 
panied by  wheezing  sounds,  often  audible  over  the  entire  room.  The 
skin  and  the  extremities  feel  cold  and  clammy,  the  pulse  is  feeble, 
very  rapid,  and  often  irregular.    In  a  typical  case  there  is  no  hoarse- 


ASTHMA  441 

iiess,  or  fever — the  temperature  may  even  be  subnormal  in  prolonged 
paroxysms — and  the  eough,  if  present,  is  infrequent,  dry,  and  short 
in  character,  bringing  up  a  mucous  expectoration.  This  contains 
Charcot-Leyden  crystals,  Curschmann's  spirals,  and  many  eosino- 
philes.  The  paroxysms  last  several  hours,  occasionally  several  days; 
they  subside  slowly,  as  a  rule,  but  sometimes  subsidence  is  abrupt, 
ending  with  a  fit  of  coughing  or  vomiting.  Considerable  exhaustion 
usually  follows  but  the  little  patient  seems  healthy  in  the  intervals, 
which  may  last  for  weeks  or  months,  depending  upon  the  exciting 
cause.  On  the  other  hand,  the  paroxysms  may  recur  at  the  same 
hour  for  several  successive  days;  if  at  all  severe,  they  naturally 
impair  the  health.  Their  severity  varies  just  as  do  their  duration  and 
frequency,  some  children  suffering  from  periodic  attacks  of  musical 
rales  for  a  few  days  at  a  time  without  any  apparent  dyspnea. 

The  type  of  asthma  called  spasmodic  bronchitis  differs  from  the 
above  mainly  in  the  amount  of  bronchial  secretion  and  the  presence 
of  fever.  It  develops  during  and  after  an  attack  of  nasal  or  bronchial 
catarrh,  or  follows  measles  or  whooping-cough.  The  paroxysms  usually 
come  on  at  night,  the}'  vary  in  frequency,  and  are  characterized  by 
an  increasing  dyspnea,  a  feeble  pulse,  and  dry  rales.  After  two  or 
three  days  the  child  appears  perfectly  well  except  for  a  few  rales,  and 
perhaps  a  slight  cough.  During  an  attack  the  thorax  is  held  in  the 
position  of  full  inspiration  with  the  diaphragm  depressed  and  the 
respiratory  muscles  contracted.  Only  a  slight  recession  of  the  soft 
parts  is  visible  during  inspiration.  Diffused  loud  wheezing  and  rales, 
which  at  first  are  dry,  then  moist,  and  later  mostly  expiratory,  obscure 
the  vesicular  murmur.  In  prolonged  cases  a  hyperresonant  percussion 
note  reveals  emphysema,  which  in  children  rapidly  becomes  extreme, 
but  quickly  subsides  unless  protracted  by  frequent  and  prolonged 
paroxysms.  In  asthmatic  bronchitis  there  is  practically  no  hyper- 
resonance  but  inspiratory  recession  of  the  soft  parts  and  lowering  of 
the  ribs  become  marked.    Many  fine  rales  are  heard  at  the  bases. 

Diagnosis. — The  special  diagnostic  features  of  asthma  are:  sudden 
onset,  recovery  when  the  symptoms  are  apparently  most  alarming, 
the  absence  of  fever,  and  recurrent  attacks  of  inspiratory  dyspnea 
out  of  proportion  to  the  physical  signs.  With  these  in  mind,  it  should 
not  prove  difficult  to  differentiate  the  condition  from  cardiac,  renal, 
or  diabetic  dyspnea.  Enlargement  of  the  thymus  or  the  bronchial 
glands,  as  an  etiological  factor,  can  best  be  excluded  by  an  a'-ray 
examination.  The  dyspnea  of  retropharyngeal  abscess,  or  of  laryngeal 
obstruction,  and  of  inflammatory  affections,  is  decidedly  inspiratory, 
while  the  difficult  breathing  of  hysteria,  though  it  may  occur  in 
paroxysms,  does  not  cause  distress. 

Prognosis. — The  prognosis  is  the  more  favorable  the  shorter  the 
duration,  the  younger  the  patient,  and  the  less  pronounced  the  heredi- 
tary taint.  A  cure  may  be  effected  by  the  removal  of  the  local  exciting 
cause,  or  by  a  change  of  climate.  Towards  puberty  an  abatement  and 
even  the  disappearance  of  the  attacks  is  not  infrequently  observed. 
With  a  poor  heredity,  a  predisposition  to  true  bronchial  asthma  may 


442  DISEASES  OF   THE  RESPIRATORY   TRACT 

last   for   a   lifetime,    and   may   gradually   lead   to   emphysema   and 
embarrassment  of  the  right  heart. 

Treatment. — The  importance  of  preventing  an  attack  by  proper 
hygienic  measures,  rather  than  by  relying  upon  means  simply  to  relieve 
o"r  to  abort  it,  hardly  needs  emphasis.  Everything  should  be  done 
to  remove  the  exciting  cause  and  to  improve  the  general  health  and 
the  underlying  nervous  condition.  Systematic  breathing  exercises 
are  of  great  value.  Sometimes  a  radical  change  of  climate  may  be 
necessary.  The  diet  must  be  carefully  regulated;  special  attention 
should  be  paid  to  the  evening  meal,  which  should  be  light  and  taken 
sufficiently  early  to  insure  an  empty  stomach  on  retiring.  While  no 
drug  has  proven  a  specific  for  all  cases,  3  to  5  minims  of  a  1  to  1000 
solution  of  adrenalin  chloride  given  intramuscularly  often  affords 
prompt  relief;  inhalations  of  nascent  oxygen,  or  internal  doses  of 
cocain  hydrochlorate  and  apomorphin  sometimes  cut  short  the 
paroxysms.  Expiratory  pressure  on  the  thorax  is  also  helpful.  Potas- 
sium iodide  is  of  real  value  when  administered  regularly  for  periods 
of  from  four  to  six  weeks,  and  interrupted  by  a  course  of  Fowler's 
solution  for  a  fortnight.  In  certain  cases  hypodermics  of  morphine 
and  atropine  may  be  necessary  during  an  acute  attack. 

ABSCESSES    OF    THE   LUNG. 

In  fatal  cases  of  pyemia  and  of  bronchopneumonia,  multiple  small 
abscesses  are  found  postmortem,  while  tuberculous  cavities,  varying 
greatly  in  size,  are  either  single  or  multiple.  A  larger,  single,  non- 
tuberculous  abscess  is  of  rare  occurrence  in  children  and  is  mostly 
due  to  staphylococcic  or  to  streptococcic  infection;  it  may  follow 
influenza,  or  pneumonia,  or  it  may  result  from  the  aspiration  of  a 
foreign  body,  or  occasionally  from  the  breaking  down  of  a  caseous 
bronchial  gland.  The  physical  findings  are  rather  confusing,  resem- 
bling those  of  efi^usion  as  well  as  of  consolidation;  the  exploring  needle 
may,  or  may  not,  demonstrate  the  presence  of  pus. 

Sym.ptom.s. — The  symptoms  in  a  large  pulmonary  abscess  are  similar 
to  those  of  empyema — an  irregular  hectic  temperature,  ranging  between 
99°  to  102°  F.,  sweats,  progressive  emaciation,  and  marked  leukocytosis 
■ — so  that  a  difi^erential  diagnosis  of  encapsulated  empyema,  or  of 
gangrene,  or  of  a  bronchiectatic  cavity  is  often  difficult.  The  abscess 
may  cause  an  empyema  either  by  breaking  into  the  pleural  sac  or  by 
opening  into  a  bronchus  and  thus  lead  to  a  spontaneous  cure. 

Treatment. — ^The  treatment  is  practically  that  of  empyema — 
incision  after  exploratory  puncture,  drainage,  and  the  very  best  after- 
care. The  pleura  is  usually  adherent,  but,  if  not,  an  adhesion  may  be 
artificially  produced  by  packing  the  wound. 

GANGRENE  OF  THE  LUNG. 

This  disease,  due  to  anaerobic  bacteria,  is  rare  in  children  and  seldom 
diagnosed  during  lifetime.     It  affects  only  weakly  children  in  the 


ACQUIRED  ATELECTASIS,  OR  PULMONARY  COLLAPSE     443 

course  of  bronchopneumonia,  measles,  typhoid  fever,  tuberculosis 
of  the  lungs,  and  of  the  bronchial  glands,  or  it  may  follow  aspiration 
of  a  foreign  body  (especially  after  laryngeal  diphtheria),  or  septic 
embolism  or  thrombosis  originating  in  distant  parts  of  the  body. 

Pathological  Anatomy. — The  lower  lobes  are  usually  affected.  The 
process  is  generally  a  diffuse  one,  with  small,  grayish-green  scattered 
areas;  only  exceptionally  does  it  involve  a  whole  lobe  or  an  entire 
lung.  These  foci  are  often  wedge-shaped  with  their  bases  directed 
towards  the  outer  surface  of  the  lung,  indicating  a  thrombotic  or 
embolic  origin.  They  may  soften  later  on  when  they  emit  a  charac- 
teristic gangrenous  odor,  and  often  produce  large  cavities  with  ragged 
necrotic  walls,  partially  filled  with  fetid  pus. 

Symptoms. — The  constitutional  symptoms  depend  to  a  certain 
extent  upon  the  disease  of  which  the  gangrene  is  a  complication; 
they  usually  resemble  those  of  a  typhoid  state.  The  peculiar 
gangrenous  odor  of  the  breath  if  associated  with  a  dirty  green,  or  a 
sanguineous  expectoration  that  contains  necrotic  lung  tissue  separable 
into  three  layers,  is  an  unfailing  diagnostic  indication,  but  death 
often  ensues  before  active  decomposition  and  sloughing  in  the  lungs 
has  taken  place.    The  physical  signs  are  those  of  bronchopneumonia. 

Prognosis. — ^A  fatal  termination  is  the  rule,  although  modern  surgery 
has  several  cures  to  its  credit. 

Treatment. — Medicinal  treatment  should  be  directed  toward  main- 
taining the  strength  of  the  patient  by  stimulants  and  proper  feeding, 
and  toward  arresting  the  process  by  inhalations  of  antiseptics  and 
the  administration  of  the  oil  of  creosote. 

ACQUIRED    ATELECTASIS,    OR   PULMONARY   COLLAPSE. 

Pathology. — This  is  distinct  from  the  congenital  form,  inasmuch  as 
the  lung  had  expanded  after  birth.  It  is  not  infrequently  seen  in 
young  children.  It  may  result  from  pleuritic  or  pericardial  effusions 
so  compressing  portions  of  the  lung  that,  although  the  bronchi  remain 
open,  the  alveoli  collapse;  after  a  certain  time  tissue  alterations 
occur  which  make  their  reexpansion  difficult,  or  even  impossible. 

Similar  changes  take  place  when  a  bronchus  is  blocked,  for  instance, 
by  a  foreign  body;  in  time  the  air  beyond  the  obstruction  becomes 
absorbed,  and  that  part  of  the  lung  collapses;  finally,  atelectasis  may 
be  acquired  by  marantic,  or  greatly  debilitated  children  with  feeble 
inspiratory  force;  this  is  especially  the  case  in  rickets,  where  weak 
musculature  and  very  fiexible  ribs  interfere  with  thorough  aeration 
of  the  lungs. 

Symptoms. — The  symptoms  are  more  or  less  marked,  and  resemble 
those  of  the  congenital  form.  Rapid  superficial  respiration,  mspha- 
tory  dyspnea,  and  cyanosis  of  varying  degree,  with  a  feeble  vesicular 
murmur,  and  normal  or  even  subnormal  temperature  point  strongly 
to  atelectasis. 

Treatment. — The  treatment  follows  the  principles  laid  down  for  the 
congenital  form  of  the  disease.  -As  a  prophylactic  measure,  all  young 


444  DISEASES  OF   THE  RESPIRATORY   TRACT 

infants  should  be  taken  up,  or  turned  o^'er  on  the  a})domen,  several 
times  a  day.  This  is  especially  necessary  if  the  child  is  suffering  from 
rachitis. 

EMPHYSEMA. 

The  peculiar  structiu*e  of  the  lung  favors  the  occiu-rence  of  acute 
emphysema  in  young  children,  and  especially  so  if  the  patient  is 
rachitic,  but  most  cases  of  emphysema  subside  quicklj-  after  the  termi- 
nation of  the  primary  disease.     Usually  three  forms  are  differentiated. 

In  one,  called  compensatory,  the  alveoli  of  certain  portions  of  the 
lung  become  overdistended  from  an  effort  to  compensate  for  deficient 
aeration  of  other  parts;  as,  for  example,  in  pneumonia,  tuberculosis, 
and  when  there  is  diminished  expansion  caused  by  adhesions,  thickened 
pleura,  or  external  pressure. 

The  second  form  causes  the  same  pathological  lesions,  but  depends 
more  upon  an  obstruction  to  expiration  or  a  prolonged  cough — the 
vesicles  becoming  distended  because  the  air  cannot  readily  escape — 
as  seen  in  pertussis,  bronchitis,  and  all  forms  of  laryngeal  stenosis. 

A  third  kmd,  so-called  interstitial  emphysema,  in  which  air  from 
ruptm-ed  air  vesicles  escapes  into  the  interstitial  and  even  subcutaneous 
tissues,  is  very  rare  indeed. 

Pathological  Anatomy. — ^The  adult  form  of  more  or  less  general 
emphysema  with  permanently  enlarged  alveoli  and  dilated  right  heart 
is  hardly  ever  seen  in  young  children.  The  thorax  is  not  barrel-shaped, 
but  may  be  abnormally  full  just  beneath  the  clavicle.  On  opening 
the  chest,  the  lung  does  not  readily  collapse.  Certain  localized  areas, 
principally  around  the  apices  and  anterior  borders,  are  raised,  feel 
velvety,  look  whitish-yellow,  and  crepitate  under  the  finger.  Usually 
only  a  few  septa  are  ruptured,  but  in  more  severe  cases  (pertussis) 
blebs  of  fairly  large  size  may  be  seen. 

Symptoms. — ^The  signs  in  <^ases  of  emphysema  which  occurs  in  acute 
pulmonary  disease  are  not  very  distinctive.  There  may  be  hyper- 
resonance  over  the  emphysematous  areas,  prolonged  expiration,  and, 
perhaps,  diminished  tactile  and  vocal  fremitus.  The  ordinary  dulness 
of  heart,  liver,  spleen,  and  consolidated  lung  is  not  infrequently  masked 
or  diminished  by  overlying  emphysematous  lung  tissue.  The  symp- 
toms are  principally  those  of  the  underlying  disease,  and  on  its  sub- 
sidence disappear  in  a  comparatively  short  time.  Fat,  pasty-looking 
children, with  flabby  musculature  are  especially  prone  to  the  affection. 

Treatment. — ^The  treatment  resolves .  itself  chiefly  into  that  of  the 
primary  disease;  i.  e.,  bronchitis,  asthma,  pertussis,  etc.  Outdoor 
life  is  essential,  but  undue  exposure  must  be  avoided.  Both  country 
and  mountain  air  offer  undoubted  advantages.  During  convalescence, 
a  course  of  arsenic,  interrupted  after  a  few  weeks  by  the  admmistration 
of  small  doses  of  the  iodides,  certainly  does  good.  In  the  rare  subcu- 
taneous forms  of  emphysema,  the  skin  is  punctured,  the  air  pressed 
out,  and  mechanical  means — that  is,  compression  of  the  chest  during 
expiration — may  be  used  to  relieve  the  dyspnea. 


CHAPTER  XV. 
DISEASES  OF  THE  HEART. 

Cardiovascular  diseases  are  more  common  in  children  than  is  gener- 
ally assiim.ed,  often  beginning  in  early  childhood,  especially  among 
the  poorer  classes.  They  are  less  com.plex  and  appear  in  fewer  forms 
than  in  the  adult,  but  are  by  no  means  less  severe.  In  order  to  under- 
stand and  to  differentiate  diseases  of  the  heart,  the  physician  m.ust 
have  accurate  knowledge  of  the  anatomy  and  physical  peculiarities 
of  the  circulatory  apparatus,  both  in  infancy  and  childhood,  and  of 
its  mode  of  developm.ent. 

As  the  prim.ary  cardiac  tube  develops,  it  is  gradually  transform.ed 
by  constriction,  sigm.oid  twisting,  and  the  formation  of  internal  septa, 
into  the  fetal  heart.  Fetal  circulation  differs  chiefly  from  the  circu- 
lation after  birth  in  the  fact  that,  with  the  exception  of  the  umbilical 
veins,  which  carry  pure  arterial  blood,  most  of  the  bloodvessels  con- 
tain a  mixture  of  arterial  and  venous  blood;  that  is,  the  systemic 
and  the  pulmonary  circulations  have  not  as  yet  become  distinctly 
established. 

The  Heart. — In  children  the  organ  is  relatively  larger  than  in 
adults,  as  are  also  the  lumina  of  the  bloodvessels.  As  a  natural  con- 
sequence, the  blood-pressure  in  early  childhood  is  lower  than  in  adults, 
and  increases  toward  puberty  as  the  relative  narrowness  of  the  arterial 
system  increases. 

At  birth  the  heart  weighs  from,  one-half  to  one  ounce,  doubles  this 
weight  by  the  end  of  the  second  year,  increases  to  two  and  one-half 
ounces  by  the  fifth  year,  and  to  about  five  ounces  by  the  fourteenth 
year;  thus  the  most  rapid  increase  is  in  the  first  year  and  toward 
puberty. 

In  this  connection  it  is  interesting  to  note  that,  while  the  total 
body  weight  of  the  adult  is  twenty  times  as  great  as  at  birth,  the 
adult  heart  is  only  fifteen  times  its  original  weight;  also  that,  while 
the  walls  of  the  right  and  left  ventricles  are  in  early  infancy  alm_ost 
equal  in  thickness,  the  left  is  twice  as  thick  as  the  right  toward  the  end 
of  the  sixth  year. 

The  circumierence  of  the  heart  increases  but  little  during  the  first 
five  years,  but  the  heart  muscle  grows  stronger;  therefore  there  is  no 
corresponding  increase  in  the  size  of  the  cavities.  After  the  fifth  year, 
however,  the  increase  in  the  size  of  the  cavities  corresponds  more 
nearly  to  the  increase  in  the  size  of  the  organ.  \Yhile  the  total  size 
of  the  heart  becomes  twelve  times  as  great  between  infancy  and  ado- 
lescence, the  aorticorificebecom.es  only  three  times  as  large  as  at  birth. 


446  DISEASES  OF  THE  HEART 

In  fact,  the  obstacles  which  the  cardiac  muscle  has  to  overcome  find 
expression  in  a  gradual  rise  of  the  blood-pressure  which,  in  the  first 
and  second  year,  reaches  80  to  85  mm.;  at  the  seventh  year  is  between 
90  and  95  mm.;  from  the  eighth  to  the  tenth  year  is  95  to  100  mm.; 
and  thence  to  puberty  is  100  to  110  mm. 

The  Pulse. — In  childhood  the  pulse  is  very  rapid,  the  number  of 
beats  varying  from  120  to  140  at  birth  to  100  to  120  at  the  end  of  the 
first  year,  then  diminishing  by  about  five  beats  a  year  until  the  tenth 
year,  when  the  average  is  about  80  for  boys  and  90  for  girls.  Both  its 
rate  and  regularity  are  influenced  by  even  trivial  causes,  such  as  cry- 
ing, excitement,  accelerated  respiration,  and  sleep. 

The  Apex  Beat. — The  location  of  the  apex  beat  varies  not  only  in 
difi'erent  children,  but  also  in  the  sam.e  child  at  different  tim.es,  follow- 
ing no  definite  rule.  Generally  speaking,  it  is  a  little  higher  in  infancy 
than  it  is  later.  Up  to  the  fourth  year  it  is  found  just  outside  the  nipple 
line;  from,  the  fourth  to  the  seventh  year  at  the  nipple  line;  subsequently 
a  little  lower,  but  well  within  the  m.amm.ary  line,  according  to  the  shape 
and  development  of  the  chest,  and  the  position  the  child  is  in.  It  m.oves 
laterally  as  the  child  turns,  and  sinks  when  it  assumes  the  erect  or  hori- 
zontal posture.  Up  to  the  fifth  year  it  is  usually  found  in  the  fourth 
interspace,  and  later  sinks  to  the  fifth. 

In  recent  years  great  progress  has  been  made  in  the  study  of  func- 
tional disorders  and  diseases  of  the  heart  in  childhood.  But,  in  order 
to  investigate  these  with  an  open  m.ind,  one  must  disregard  experience 
gained  from  the  study  of  the  adult  heart,  upon  which  degenerated 
arteries,  chronic  bronchitis,  emphysema,  chronic  renal  disease,  and 
poisons  (alcohol  and  syphilis)  exert  such  a  powerful  etiological  action, 
these  factors  being  practically  non-existent  in  childhood,  many  forms 
of  cardiac  disturbance  at  this  early  age  being  non-organic  in  nature. 

This  period  of  life  has  its  own  problems  and  peculiarities.  Not  only 
is  the  vasomotor  tone  of  the  arteries  unstable,  but  the  nerve-control- 
ling mechanism,  central  as  well  as  peripheral,  and  even  the  heart  itself, 
show  great  instability.  They  are  readily  disturbed  because  not  yet  fully 
developed.  We  must  therefore  allow  ourselves  considerable  latitude 
when  considering  physiological  cardiac  m.anifestations,  and  be  cautious 
in  regarding  them  as  pathological. 

Even  real  lesions  which  affect  the  auricular  and  ventricular  muscular 
tissue  m.ay,  if  limited  in  extent,  be  com.pletely  compensated  by  norm.al 
growth.  In  discriminating  between  those  signs  which  are  of  no  sig- 
nificance and  those  which  point  to  actual  disease,  it  is  extrem.ely  impor- 
tant to  consider  what  the  heart  is  capable  of  doing  when  the  child  is  at 
rest,  and  also  when  exercising,  rather  than  the  sounds  produced.  While 
in  later  life  the  changes  produced  by  heart  disease  are  degenerative 
and  fibrotic  in  nature,  in  the  early  stages  of  heart  disease  in  children 
these  changes  are  inflammatory  in  nature,  and  do  not,  as  a  rule,  pro- 
duce dyspnea,  cough,  or  edema. 

General  Symptomatology  and  Diagnosis. — The  symptoms  of  cardiac 
disease  depend  chiefly  upon  the  anatomical   structure  and  physio- 


MURMURS  447 

logical  function  of  the  organ,  and  the  nature  of  the  morbid  process 
affecting  it.  Although  the  symptoms  are  less  complex  than  in  adults, 
since  secondary  conditions  in  remote  regions  (such  as  dropsy  or  con- 
gestion of  parenchymatous  organs)  are  usually  lacking  in  early  child- 
hood, yet  the  physical  examination  calls  for  greater  precision,  since 
everything  depends  upon,  accurate  observation,  and  the  chief  difficul- 
ties are  in  deduction,  not  in  method.  In  regard  to  the  mode  of  examin- 
ing the  heart  it  may  be  well,  however,  to  state  that  in  the  case  of  strug- 
gling children  it  is  best  to  use  the  ear,  and,  instead  of  a  stethoscope,  a 
phonendoscope  which,  being  flat,  can  easily  be  placed  in  the  axilla  or 
under  the  back  without  raising  the  child  from  the  bed. 

The  pulse  gives  us  little  information,  there  being  neither  arterial 
degeneration,  marked  irregularity  in  rate,  nor  variability  in  strength; 
but  the  continuous  rapidity  and  progressive  diminution  in  volume  in 
acute  pericarditis  and  the  arterial  spasm,  and  heightened  blood-press- 
ure in  renal  disease  are  quite  significant.  Disturbance  of  rhythm  is 
not  at  all  uncom.m.on;  indeed,  arrhythmia  may  be  said  to  be  almost 
physiological  in  infancy,  especially  during  sleep.  It  is  also  apparent 
after  infectious  diseases,  and  in  the  early  stages  of  tuberculous  m.en- 
ingitis  m.ay  be  marked,  but  is  of  significance  only  in  diphtheria.  In 
older  children  the  sole  assignable  cause  for  it  is  a  neurotic  disposition. 
In  contradistinction  to  arrhythmia  due  to  myocarditis,  the  harmless 
arrhythmia  of  childhood  disappears  with  increase  in  the  pulse  rate 
due  to  fever  or  exertion. 

Transitory  tachycardia,  which  appears  during  the  course  of  fevers 
and  is  readily  produced  by  excitement,  is  most  m.arked  in.  neurotic 
children.  Even  in  the  older  neurotic  child,  excitement  and  exertion 
often  make  the  pulse  extrem.ely  rapid  and  com.pressible ;  this,  however, 
is  of  no  significance,  even  if  accompanied  by  a  diffuse  apex  beat. 
Accelerated  pulse  rate  induced  by  moderate  exertion,  and  not  abating 
after  three  minutes  of  rest,  suggests  weakness  of  the  heart  m.uscle. 

Paroxysro.al  tachycardia,  in  som.e  cases  hereditary,  has  been  observed 
in  older  children.  Although  not  amenable  to  treatm.ent,  it  usually 
subsides  under  hygienic  management  and  judicious  exercise.  Hoch- 
singer  mentions  a  perm.anent  tachycardia  due  to  the  pressure  of 
enlarged  bronchial  glands  upon  the  pneum.ogastric  nerve. 

Bradycardia  is  common  in  infants.  In  older  children  it  is  frequently 
associated  with  arrhythmia,  and  is  most  likely  to  occur  in  diphtheria, 
but  may  be  pronounced  in  infectious  myocarditis.  In  rare  cases,  it 
accompanies  appendicitis. 

MURMURS. 

There  are  cardiac  disturbances  which  produce  no  changes  that  can 
be  detected  by  percussion,  these  being  apparent  only  on  auscultation. 
In  children,  as  a  rule,  cardiac  sounds  are  loud;  only  in  very  young 
infants  are  they  dull,  or  even  impure. 

Bruits,  or  murmurs,  are  frequently  found,  and  during  the  first  two 
years  of  life  they  usually  indicate  congenital  disease  of  the  heart.    iVt 


448  DISEASES  OF   THE  HEART 

this  early  age  acquired  as  well  as  accidental  murmurs  are  rare.  Albu- 
minuria does  not  always  signify  renal  disease;  neither  does  a  cardiac 
murmur  in  itself  necessarily  mean  heart  disease.  The  important  thing 
is  to  decide  whether  the  working  power  of  the  heart  is,  or  is  likely  to 
be,  affected,  and  to  decide  this  question  a  clear  distinction  must  be 
made  between  organic  disease  in  childhood  (congenital  or  acquired 
valvular,  or  acquired  pericardial)  and  so-called  functional  or  accidental 
(extracardial  or  cardiopulmonary)  disorder.  Functional  murmurs 
are  very  common  in  childhood,  especially  during  school  age.  In  school 
children  one  often  finds  a  soft  systolic  murmur  over  the  pulmonic 
area.  Some  observers  with  modern  sensitive  stethoscopes  may  find 
them  in  even  a  great  number.  When  faint  they  are,  however,  more 
interesting  to  the  observer  theoretically  than  of  practical  importance 
to  the  patient.  While  there  is  no  doubt  that  distinct  murmurs  of  this 
type  have  been  found  even  in  children  under  two  years  of  age,  they 
are,  as  a  rule,  rare  before  the  fourth  year. 

Three  types  of  functional  murmurs  may  appear  between  early 
life  and  puberty;  (1)  a  pulmonary  systolic  murmur,  so  common  that 
it  may  be  considered  almost  physiological;  (2)  a  cardiopulmonary  mur- 
mur; (3)  a  systolic  murmur  of  cardiac  atonicity  which,  although  pro- 
duced at  the  valve,  does  not  signify  cardiac  disease.  In  the  other 
types,  accidental  murmurs  are  probably  caused  by  the  more  rapid 
circulation  together  with  decreased  viscosity  of  the  blood. 

1.  Pulmonary  Systolic  Murmurs. — In  this"  type  of  murmur  the 
maximum  intensity  is  between  the  second  and  third  costal  cartilages 
close  to  the  sternum,  and  is  either  limited  to  this  area,  or,  in  exceptional 
cases,  may  extend  a  few  inches  to  the  left,  sometimes  being  faintly 
audible  even  at  the  apex.  This  bruit  with  an  accentuated  second  pul- 
monic sound  is  almost  physiologic  in  children,  and  usually  disappears 
at  puberty.  Its  origin  is,  no  doubt,  at  the  pulmonary  valve,  and  it  is 
probably  due  to  the  rush  of  the  blood  through  a  narrow  ostium  into 
the  relatively  wide  pulmonary  artery.  The  murmur,  itself,  may  be 
very  distinct,  but  it  is  always  soft,  blowing,  and  short,  and  follows 
closely  upon  the  first  sound.  It  is  not  accompanied  by  any  symptoms 
of  heart  disease,  and  has  no  bearing  on  the  future  health  of  the  child. 
It  should  be  differentiated  from  a  congenital  pulmonary  murmur,  which 
is  usually  rougher,  more  rasping,  and  of  longer  duration,  and  is  often 
accompanied  by  dilatation  of  the  right  ventricle  and  weakening  of  the 
second  pulmonic  sound. 

2.  Cardiopulmonary  Murmurs. — These  murmurs  are  extracardiac  in 
origin,  and  are  caused  by  changes  in  the  lungs  which  occur  during  the 
systolic  contraction  of  the  heart.  Whether  the  murmurs  are  the  result 
of  aspiration  of  air,  friction  of  the  lungs  and  the  heart,  or  the  simul- 
taneous vibration  of  the  lungs  and  heart,  has  not  been  fully  explained. 
The  bruit  varies  during  the  respiratory  movements,  being  intensified 
at  inspiration,  diminished  at  e^cpiration,  and  disappearing  when  breath- 
ing is  suspended.  It  is  usually  heard  between  the  apex  and  the  ensi- 
form  cartilage,  but  may  vary  with  the  child's  position  and  the  rate  of 


MURMURS  449 

the  heart;  it  is  always  systolic  in  time,  soft  and  superficial  in  character, 
and  in  rare  cases  only  is  accompanied  by  a  whiffing  sound  during  the 
diastole.  It  not  infrequently  diminishes  or  disappears  altogether 
under  firm  pressure  of  the  stethoscope  on  the  elastic  chest  wall.  For- 
tunately, neither  the  patient  nor  his  heart  is  aft'ected,  no  symptoms 
are  produced,  and  it  is  of  no  prognostic  significance. 

3.  Intracardiac  Murmurs. — Presumably  valvular  in  origin,  these 
murmurs  may  occur  without  the  existence  of  any  organic  lesion,  and 
are  probably  due,  in  part,  to  temporary  insufficiency  of  either  the  car- 
diac muscle  or  the  papillary  muscles  of  the  mitral  valve,  this  causing 
reflux  of  blood  with  or  without  a  systolic  murmur,  the  mitral  valves 
themselves  remaining  perfectly  intact.  A  similar  condition  is  often 
found  during  and  after  specific  fevers,  and  disappears  during  con- 
valescence. Both  of  these  murmurs  are  probably  due  to  atonicity 
of  the  cardiac  muscle.  The  former  appears  in  overgrown,  neurotic 
girls,  and  passes  away  after  rest  or,  in  some  children,  on  taking  active 
exercise. 

Anemia,  in  itself,  cannot  be  considered  the  sole  cause,  because  many 
anemic  children  never  present  a  murmur;  but  in  neurotic  and  neuras- 
thenic children  a  disturbed  or  enfeebled  condition  of  the  central  ner- 
vous system  may  manifest  itself  by  debility  which  leads  to  cardiac 
murmurs.  It  must  be  understood  that  whenever  general  debility  is 
present,  whatever  its  origin,  this  is  shared  by  the  heart  and  causes 
a  tendency  to  murmurs.  Therefore,  loss  of  tonicity  of  the  heart 
muscle  prevents  the  prompt  and  complete  closure  of  the  valve  seg- 
ments^n  other  words,  the  murmur  is  not  valvular,  but  myocardial. 

How  can  we  difterentiate  these  from  organic  murmurs  ?  By  consider- 
ing the  murmur  itself,  and  by  noting  the  presence  or  absence  of  con- 
stitutional local  disease.  A  functional  cardiac  murmur  is  always  sys- 
tolic in  time,  usually  soft,  blowing,  and  short,  and  involves  almost 
exclusively  the  left  heart — that  is,  the  pulmonic,  rarely  the  mitral 
area.  The  heart  sounds  may  be  altered,  but  not  absent;  they  vary 
more  in  time  than  do  organic  murmurs,  being  present  at  one  time  and 
absent  at  another,  and  also  vary  with  the  posture,  as  when  the  child 
lies  down  or  sits  up,  and  after  exercise. 

When  cyanosis,  dilatation  of  the  right  heart,  and  clubbing  of  the 
fingers  and  toes  are  marked,  and  associated  with  a  loud  rasping  mur- 
mur, it  is  not  difficult  to  recognize  a  congenital  origin;  but  when  the 
murmur  is  the  only  evidence  it  is  sometimes  hard  to  differentiate 
congenital  from  functional  murmurs.  HoM^ever,  for  practical  purposes, 
this  is  of  little  importance  when  other  signs  and  symptoms  of  heart 
disease  are  lacking.  Only  long-continued  observation  will  enable  us 
definitely  to  determine  the  underlying  lesion,  and  make  an  accurate 
diagnosis.  Summarizing,  we  would  say  it  is  most  important  to  realize 
that  functional  murmurs  not  only  exist  but  are  common  in  children, 
and  that  the  mere  presence  of  a  murmur  does  not  necessarily  indicate 
disease  of  the  heart. 

Reduplication  of  the  second  pulmonary  sound  may  occiu"  in  healthy 
29 


450  DISEASES  OF  THE  HEART 

little  children  as  the  result  of  crying  or  excitement,  the  closure  of  the 
pulmonary  valve  preceding  that  of  the  aorta.  A  faint  venous  hum  in 
older  children  is  not  infrequently  heard  at  both  sides  of  the  sternum, 
diminishing  when  the  child  assumes  the  horizontal  position.  A  similar, 
but  long  and  almost  continuous,  bruit  is  sometimes  heard  to  the  right 
of  the  sternum  at  about  the  third  intercostal  space,  and  is  increased 
during  the  systole;  it  apparently  originates  in  the  superior  vena  cava, 
but  varies  considerably.  This  occurs  chiefly  in  the  anemic  child; 
but  when  dealing  with  the  tuberculous  patient  it  may  suggest  the  pos- 
sibility of  compression  by  enlarged  bronchial  glands. 

In  deciding  whether  organic  heart  disease  is  acquired  or  congenital, 
the  following  points  are  worthy  of  consideration:  loud,  rough,  musical 
murmurs  without  increase  in  cardiac  dulness,  or,  in  the  first  and  second 
years,  such  bruits  with  a  weak  apex  beat  and  increased  cardiac  dulness, 
as  well  as  bruits  preponderating  in  the  pulmonary  area,  all  indicate 
congenital  heart  disease;  very  loud  mumurs  all  over  the  heart,  without 
a  thrill,  indicate  a  patent  septum.  A  systolic  murmur  with  a  thrill, 
its  maximum  intensity  over  the  upper  part  of  the  sternum,  and  no 
cardiac  h^-pertrophy,  indicates  in  all  probability  an  open  ductus 
arteriosus.  Arteriosclerosis,  chronic  myocarditis,  poisoning  by  tobacco 
or  alcohol,  or  a  fatty  heart  is  only  exceptionally  found  when  studying 
diseases  of  the  heart  in  children. 

CONGENITAL   DISEASES    OF    THE    HEART. 

The  complicated  normal  process  by  which  the  simple  tube  of  the 
primordial  heart  becomes  transformed  into  a  sj^stem  of  contractile 
spaces  is  a  masterpiece  of  art  that  even  Nature  does  not  always  succeed 
in  carrying  out  to  perfection.  It  can  readily  be  understood  that  devia- 
tions of  the  simple  parts  from  the  normal  in  size,  direction,  or  position, 
due  to  disease  or  other  adverse  factors  which  must  be  in  operation 
early  in  fetal  life,  should  leave  some  defect  in  the  heart's  otherwise 
perfect  structure.  Another  element,  fetal  endocarditis,  or  an  inflam- 
mation set  up  soon  after  birth,  may  in  itself  cause  cardiac  disease. 
However,  not  all  congenital  cardiac  diseases  can  be  attributed  to  either 
mechanical  or  embryonic  causes. 

Most  of  these  conditions  are  due,  not  to  disease,  but  to  faulty  devel- 
opment. In  15  per  cent,  of  the  cases  they  form  only  one  of  several 
deformities,  such  as  cleft-palate,  undescended  testicle,  supernumerary 
or  web-fingers,  talipes,  or  microcephaly,  and  are  evidently  the  expres- 
sion of  a  general  tendency  to  maldevelopment  or,  as  in  Mongolian 
imbecility,  exhaustion  products.  Depressing  influences  which  impair 
the  mother's  perfect  power  of  reproduction  (syphilis,  for  example), 
or  poisons  which  act  upon  the  embryo,  such  as  alcohol,  tobacco,  lead, 
or  mercury,  are  undoubtedly  important  etiologic  factors,  and  give 
evidence  of  their  effect  sometimes  in  two  or  three  members  of  one 
family.  Most  cases,  however,  are  due  to  faulty  development,  and  only 
very  few  to  so-called  fetal  endocarditis. 


CONGENITAL  DISEASES  OF   THE  HEART 


451 


In  the  order  of  their  frequency  lesions  take  place  as  follows:  A 
defect  in  the  ventricular  septum;  a  defect  in  the  auricular  septum; 
pulmonary  stenosis;  patent  ductus  arteriosus;  abnormal  origin  of  the 
great  vessels.  In  the  great  majority  of  these  cases  there  are  several 
lesions,  consequently  a  correct  diagnosis  is  difficult,  and  sometimes 
practically  impossible. 

Clinical  Symptoms. — The  most  striking  symptom  is  cyanosis,  which 
is  present  in  many  severe  cases,  but  absent  in  about  60  per  cent.  It 
may  manifest  itself  at  birth  or  soon  after,  giving  the  skin  and  mucous 
membrane  a  dark  leaden  color,  if  intense,  and  when  slight  a  bluish 


Fig.  32.— Infant's  heart,  showing  congenital  lesions.  The  right  ventricle  laid  open, 
incision  extending  outward  through  the  aorta,  which  communicates  with  both  ventricles. 
The  aorta  is  open  and  its  valve  leaflets  are  shown  at  A  A  A.  Between  D  and  E  is  the 
incision  which  extends  outward  through  the  pulmonary  artery.  B  and  C  are  leaflets  of 
the  tricuspid  valve.  D,  the  sinus  that  communicates  with  the  pulmonary  artery  and  con- 
stitutes the  opening  of  the  vessel  in  the  right  ventricle.  E,  the  semilunar  communica- 
tion between  the  two  ventricles  just  below  the  aortic  orifice. 


tint  on  coughing  or  crying;  although  healthy  infants  also  may  turn 
cyanotic  during  a  prolonged  crying  spell.  Some  children  show  a  slight 
bluish  color  only  in  the  finger  tips  and  toes.  Marked  cyanosis  may 
not  appear  before  puberty,  and  in  other  cases  it  becomes  more  obvious 
year  by  year.  It  has  a  certain  value  in  prognosis,  inasmuch  as  cases 
in  which  the  cyanosis  is  severe  usually  do  not  live  long,  while  in  the 
less  severe,  or  those  in  which  it  appears  only  in  later  life,  the  prognosis 
is  more  favorable. 

This  cyanosis  seems  to  be  partly  due  to  obstruction  of  the  lungs, 
deficient    oxygenation,  and    to  polycythemia — that  is,  6,000,000  to 


452  DISEASES  OF   THE  HEART 

8,000,000  of  erythrocytes,  with  an  increased  amount  of  hemoglobin. 
Cyanosis  is  usually  accompanied  by  clubbed  fingers  and  toes,  probably 
owing  to  venous  obstruction.  The  respiration  in  cyanotic  cases  is 
generally  accelerated,  sometimes  difficult,  and  increases  the  tendency 
to  acute  bronchitis  or  bronchopneumonia, — the  usual  termination  of 
congenital  heart  disease. 

Edema  of  the  face  and  lower  extremities,  dropsy,  and  epistaxis  are 
comparatively  rare.  The  pulse  is  usually  small,  rapid,  and  easily 
compressible;  sometimes  it  is  irregular -in  rate  and  variable  in  strength. 
These  children  are  often  inclined  to  diarrhea,  and  especially  to  vomit- 
ing which  recurs  for  months;  they  develop  slowly,  are  undersized, 
and  are  living  problems  of  nutritional  difficulty.  Irritable  or  apathetic, 
easily  fatigued  and  short  of  breath,  complaining,  perhaps,  of  pain 
over  the  heart,  these  children  find  walking  increasingly  difficult  and 
climbing  impossible.  They  finally  cease  to  walk,  and  take  to  their 
beds,  there  to  end  their  short  lives,  dying  from  the  disease  itself  or 
some  complication,  usually  pulmonary.  Some,  however,  have  lived 
for  15  to  25  years,  and  even  beyond  this. 

Clinically,  we  distinguish  three  distinct  groups  of  congenital  diseases 
of  the  heart,  as  follows: 

I.  Abnormal  persistence  of  fetal  conditions. 

(a)  Patent  ventricular  septum. 

(b)  Patent  foramen  ovale. 

(c)  Patent  ductus  arteriosus. 
II.  Deformities  of  valves. 

(a)  Pulmonary  stenosis  or  atresia. 

(b)  Aortic  stenosis. 

(c)  Tricuspid  stenosis. 

III.  Abnormalities  of  vessels  and  of  the  cavities  of  the  heart. 

(a)  Abnormally  large  or  small  pulmonary  artery. 

(b)  Transposition  of  vessels. 

(c)  Single  ventricle  with  single  or  double  auricle.     (The  latter 

is  of   no  practical  importance,  because  such  children 

die  within  a  few  hours  after  birth.) 
I.  Abnormal  Persistence  of  Fetal  Conditions,  (a)  Defect  in  the  Ven- 
tricular Septum. — This  is  the  most  common  congenital  lesion  of  the 
heart;  and,  as  it  is  always  due  to  a  defect  in  development,  it  is  fre- 
quently associated  either  with  pulmonary  stenosis  or  other  anomaly  of 
development,  such  as  hare-lip,  etc.  The  opening  is  usually  located  in 
the  upper  membranous  part  of  the  septum,  and  is  about  one-fourth 
to  one-half  inch  in  diameter;  but  the  septum  may  be  almost  wholly 
wanting,  in  which  case  there  may  be  scarcely  any  bruit  present. 

In  the  majority  of  cases,  however,  the  defect  manifests  itself  princi- 
pally by  a  loud,  rough,  systolic  murmur  which,  although  heard  all 
over  the  heart,  is  of  maximum  intensity  in  the  second  or  third  inter- 
space close  to  the  sternum,  and  is  transmitted  to  the  back,  but  not  to 
the  carotids.  The  pulmonary  second  sound  is  almost  always  accen- 
tuated, except  in  the  cases  where  the  opening  is  minute. 


CONGENITAL  DISEASES  OF   THE  HEART  453 

In  the  later  .stages  of  the  (Hsease  a  certain  amoiint  of  liypertropliy 
and  dilatation  of  the  right  A'entriele  becomes  cleai'ly  (listinguishable. 
There  is  usnally  no  cyanosis,  and  the  general  health  is  so  little  affected 
that  the  lesion  may  be  found  accidentally  rather  than  by  intent,  and 
the  patient  live  to  old  age. 

Diagnosis  in  early  infancy  of  a  defect  in  the  ventricular  septum  is 
often  not  difficult  if  a  diffuse  systolic  murmur  is  detected,  with  its 
maximum  intensity  close  to  the  left  side  of  the  sternum,  with  no  change 
in  cardiac  dulness,  with  an  accentuated  second  pulmonic  sound,  and 
absence  of  cyanosis.  In  later  childhood  similar  signs  on  percussion 
and  auscultation  may  be  found  in  diseases  of  the  mitral  valve;  but  the 
maximum  intensity  is  at  the  apex,  and  the  less  rough  and  more  local- 
ized character  of  the  murmur,  with,  possibly,  a  history  of  rheumatic 
infection,  will  help  in  the  differentiation.  When  the  lesion  is  asso- 
ciated with  open  ductus  arteriosus,  pulmonary  stenosis,  or  both,  a 
positive  diagnosis  is  often  difficult,  and  the  prognosis  is  poor. 

(b)  Patent  Foramen  Ovale. — This  is  of  very  frequent  occurrence, 
but  is  not  always  recognized  during  life  because  it  may  give  rise  to 
no  symptoms  whatever. 

(c)  Persistent  Ductus  Arteriosus.— The  ductus  arteriosus  should 
close  during  the  first  four  weeks  after  birth  by  overgrowth  of  the  cells 
in  its  inner  w^all.  Under  abnormal  conditions,  such  as  atelectasis  or 
cardiac  defects,  these  cells  break  down  and  the  duct  remains  open. 
It  seldom  occurs  alone,  being  usually  associated  with  defects  of  the 
septum  or  the  pulmonary  valve. 

During  early  life  a  systolic  murmur  is  heard,  its  maximum  intensity 
being  at  the  pulmonary  area,  and  probably  caused  by  the  whirl  pro- 
duced by  the  meeting  of  blood  streams  from  the  pulmonary  artery  and 
the  aorta.  The  bruit  is  transmitted  to  the  carotids.  In  later  life  a 
distinct  thrill  is  felt  over  the  base  of  the  heart.  The  second  pulmonary 
sound  is  accentuated ;  the  upper  portion  of  the  sternum  may  be  bulging. 
Hypertrophy  and  dilatation  of  the  right  ventricle  as  well  as  dilatation 
of  the  pulmonary  artery  rapidly  take  place,  and  may  be  demonstrated 
by  dulness  in  the  second  intercostal  space. 

In  uncomplicated  cases  the  general  health  may  be  undisturbed  for 
a  long  time.  There  is  rarely  dyspnea  or  cyanosis;  on  the  contrary  a 
deathly  pallor  is  often  seen.  Subsequently  there  is  a  disposition  to 
catarrh.  The  diagnosis  can  be  definitely  made  only  in  cases  uncompli- 
cated by  other  congenital  cardiac  defects. 

II.  Deformities  of  Valves.  Pulmonary  Stenosis. — Of  much  greater 
clinical  importance  is  pulmonary  stenosis,  which  is  one  of  the  most 
common  and  serious  congenital  lesions  due  either  to  malformation 
or  fetal  endocarditis.  The  stenosis  may  be  slight  or  grow  to  almost 
complete  atresia,  and  may  be  situated  at  the  pulmonary  orifice  in  the 
conus  arteriosus  or  in  the  pulmonary  artery  just  beyond  the  valve. 
It  is  compatible  with  long  life  when  association  with  other  defects 
compensates  for  it;  for  instance,  when  there  is  a  patent  ductus  arte- 
riosus which  permits  the  blood  to  flow  to  the  lungs  from  the  aorta,  and 


454  DISEASES  OF   THE  HEART 

a  patent  ventricular  septum  which  allows  blood  to  flow  to  the  left 
ventricle  that  cannot  be  forced  through  the  stenotic  pulmonary  valve 
to  the  lungs. 

Cyanosis  more  constantly  accompanies  pulmonary  stenosis  than 
any  other  congenital  heart  lesion.  It  is  usually  marked  at  birth,  and 
increases  to  a  dark  slate  color  on  crying  or  any  other  exertion.  Club- 
bing of  the  fingers  and  toes  is  especially  marked.  There  is  a  decided 
tendency  to  lung  affections,  dyspnea,  dizziness,  vertigo  and  attacks 
of  suffocation. 

A  loud  systolic  murmur  in  the  left  second  interspace  and  a  lacking 
or  weakened  second  pulmonary  sound  are  characteristic.  The  murmur 
is  not  transmitted  to  the  vessels  of  the  neck  except  when  due  to  a 
defective  interventricular  septum;  the  blood  rushes  directly  to  the  left 
ventricle,  and  thence  to  the  aorta,  ^^^ae^  associated  with  an  open 
ductus  arteriosus  the  second  pulmonic  sound  may  be  accentuated, 
and  the  murmur  together  with  a  thrill  be  transmitted  to  the  carotids. 
After  a  lapse  of  years  dilatation  and  hypertrophy  of  the  right  ventricle 
become  marked,  and  in  many  cases  death  occurs  from  pulmonary 
tuberculosis. 

(&)  Congenital  Stenosis  of  the  Aorta. — This  condition  may  be  found 
at  the  point  of  origin,  at  the  entrance  of  the  ductus  Botalli,  or  through- 
out the  entire  aorta.  If  pronounced,  life  is  sustained  but  a  short 
time  while  the  blood  continues  to  circulate  tlirough  the  ductus  arte- 
riosus. Stenosis  of  the  isthmus,  i.  e.,  near  the  entrance  of  the  ductus 
arteriosus,  if  not  too  extreme,  can  be  successfully  overcome  by  hyper- 
trophy of  the  left  ventricle.  A  systolic  murmur  is  heard  over  the  upper 
part  of  the  sternum  and  the  second  pulmonic  sound  is  normal.  If  the 
patient  lives,  collateral  circulation  is  established  through  the  inter- 
costals  and  the  internal  mammary  arteries,  and  the  parts  below  the 
isthmus  are  better  supplied. 

m.  Abnormalities  of  Vessels  and  of  the  Cavities  of  the  Heart. — (a) 
Is  not  a  common  malformation,  (h)  Transposition  of  vessels  is  not 
uncommon,  and  is  always  found  to  be  associated  with  some  other 
congenital  heart  defect.  The  aorta  may  arise  from  the  right  ven- 
tricle, or  the  pulmonary  artery  from  the  left  ventricle.  Occasionally 
a  common  trunk  may  serve  as  the  origin  of  both  the  aorta  and  the 
pulmonary  artery.  Dextrocardia,  or  transposition  of  the  heart,  is 
very  rare,  (c)  This  form  of  congenital  heart  disease  is  of  little 
clinical  importance,  as  the  condition  is  usually  incompatible  with  life. 

PHYSICAL   EXAMINATION   IN   DISEASES    OF    THE    HEART. 

Physical  examination  of  the  heart  in  children  calls  for  the  greatest 
care,  everything  depending  upon  accurate  observation,  since  we  get 
little  or  no  information  from  the  child.  Generally  speaking,  the  situ- 
ation of  the  apex  beat  depends  upon  the  development  and  shape  of 
the  chest,  but  it  changes  also  with  the  position  of  the  patient.  As  a 
rule,  before  the  seventh  year  the  impulse  is  found  outside  of  the  median 


PHYSICAL  EXAMINATION  IN  DISEASES  OF  THE  HEART    455 

line,  later  at  about  the  nipple  line.  Moderate  displacement  to  the  left 
occurs  with  cardiac  hypertrophy,  especially  of  the  left  ventricle,  while 
if  to  the  right  it  suggests  hypertrophy  chiefly  of  the  right  ventricle. 
Extreme  displacement  points  to  an  outside  cause,  such  as  pleurisy  or 
empyema. 

As  mentioned  before,  the  pulse  gives  us  no  assistance  except  in  acute 
pericarditis  where  we  find  continuous  rapidity  with  progressive  diminu- 
tion in  volume,  and  in  renal  disease  where  arterial  spasm  finds  its 
expression  in  a  hard  pulse  with  high  blood-pressure. 

Inspection,  also,  is  very  unsatisfactory  in  children.  The  child  must 
be  stripped  and  examined  in  a  good  light.  In  infants  the  impulse  is 
comparatively  weak,  while  in  the  well-fed  the  chest  walls  are  so  well 
covered  that  the  apex  beat  is  invisible.  Precordial  prominence  soon 
occurs  in  young  children  with  rachitis,  or  after  this  disease;  sometimes 
also  in  hypertrophy,  and  when  there  is  a  large  pericardial  effusion. 
Valvular  disease  or  adherent  pericardium  produces  a  wide  area  of 
visible  pulsation. 

Palpation. — In  palpation  the  whole  hand  should  be  pressed  gently 
but  firmly  over  the  precordial  area  while  the  child  is  sitting  with  its 
body  bent  slightly  forward;  the  finger  will  then  quickly  find  the  point 
of  greatest  impulse.  Thrills  resulting  from  congenital  or  acquired 
heart  disease  are  easily  located,  and  the  force  of  the  systole  gauged. 

Percussion. — Percussion  is  best  performed  in  infants  while  recum- 
bent, and  in  older  children  in  the  upright  posture.  It  should  be  done 
very  lightly,  bearing  in  mind  the  extreme  thinness  and  elasticity  of 
the  chest  wall.  The  area  of  relative  cardiac  dulness  is  proportionately 
larger  in  children  than  in  adults,  and  is  the  greater  the  younger  the 
child.  Failure  to  allow  for  this  might  lead  to  an  erroneous  diagnosis 
of  hypertrophy.  As  regards  the  relative  and  absolute  cardiac  dulness, 
we  would  say  (avoiding  too  great  refinement)  that  for  most  clinical 
purposes  it  is  sufficient  to  remember  the  following  points  concerning 
their  location: 

Relative  Cardiac  Dulness. 

At  one  year.  At  six  years.                                    At  twelve  years. 

Upper  limit :    Second  costal  Second  intercostal  space.       .  Third  cartilage. 

cartilage. 

Right  margin:    Right  para-  Slightly  more  to  the  left.       About  midway  between  the 

sternal  line.  -                      parasternal  and  the  right 

border  of  the  sternum. 

Left  border:  Slightly  beyond  Slightly  beyond  the  apex     Slightly    beyond    the     apex 

the  apex  beat.  beat.                                            beat. 

Absolute  Cardiac  Dulness. 

At  one  year.  At  six  years.  At  twelve  years. 

Upper  limit :    Lower  border  Upper  border  of  fourth  rib.  Lower  border  of  fourth  rib. 

of  third  rib. 

Right  margin:  Left  border  of  Left  border  of  the  sternum.  Left  border  of  the  sternum. 

the  sternum. 

Left  border :    Does  not  quite  Does  not  quite  reach  the  Does    not    quite    reach    the 

reach  the  mammary  line.  mammary  line.  mammary  line. 


456  DISEASES  OF   THE  HEART 

Method  of  Percussion. — The  best  results  seem  to  be  obtained  by 
percussing  on  the  left  side  from  the  anterior  axillary  line  toward  the 
heart  in  lines  parallel  with  the  2d,  3d,  4th,  and  5th  interspaces,  and  on 
the  right  side  from  the  right  mammary  line  along  the  4th  interspace 
toward  the  sternum.  For  clinical  purposes,  it  is  quite  sufficient  to 
make  out  this  most  projecting  part,  which  corresponds  to  the  curve 
of  the  right  auricle  to  the  right  of  and  behind  the  sternum.  The 
younger  the  child,  the  more  difficult  it  is  to  mark  out  the  area  of  abso- 
lute cardiac  dulness,  and  it  is  certainly  more  important  to  determine 
the  apparent  size  of  the  heart  than  the  area  not  covered  by  the  lungs. 

Auscultation. — All  sounds  are  comparatively  louder  and  are  diffused 
over  a  greater  area  in  children  than  in  adults.  In  infants  the  muscular 
quality  of  the  first  sound  is  rather  of  the  type  of  the  fetal  tic  tac.  In 
children  the  second  aortic  sound  is  normally  weaker  than  the  second 
pulmonic.  Reduplication  of  the  sounds  is  not  infrequently  heard  in 
children  who  are  excited,  and  may  mean  nothing  more  than  that  the 
valves  of  the  two  sides  do  not  close  at  exactly  the  same  time.  A  dimi- 
nution or  absence  of  the  second  pulmonic  sound  is  invariably  found  in 
pulmonary  stenosis;  an  increased  apex  beat  with  a  rather  diffuse, 
dull,  first  sound,  strongly  points  to  cardiac  hypertrophy;  while  a  weak 
and  distant  apex  beat  is  highly  suggestive  of  either  dilatation  of  the 
heart  or  pericardial  effusion.  The  latter,  which  is  comparatively  rare, 
is  confirmed  by  a  friction  rub  and  pain  on  pressure  over  the  precordial 
area. 

THE    GENERAL    SYMPTOMS    OF    HEART    DISEASE. 

The  general  symptoms  of  heart  disease  are  no  indication  of  the  sever- 
ity of  the  affection,  and  even  in  children  with  serious  lesions  they  may 
be  slight  or  often  totally  absent.  As  already  mentioned,  cyanosis, 
although  a  frequent  accompaniment  of  congenital  heart  disease,  may 
be  absent,  as  evidenced  by  the  pallor  usually  seen  in  those  who  suffer 
from  aortic  disease.  In  mitral  disease  congestion  is  the  rule;  while  in 
malignant  endocarditis  the  grayish  color  and  pinched  expression  often 
tell  the  story.  Attacks  of  fainting,  sometimes  difficult  to  differentiate 
from  i^etit  mal  and  the  functional  disturbances  of  pnberty,  are  not 
rare. 

Muscular  weakness,  anemia,  malnutrition,  and  shortness  of  breath 
on  exertion,  all  call  for  an  examination  of  the  heart.  ]\Iarked  edema, 
digestive  disturbances,  and  angina  are  seldom  met  with  in  childhood; 
but  restlessness,  vomiting,  subnormal  temperature,  and  pallor  are 
grave  symptoms  in  children  suftering  from  cardiac  disease. 

Although  the  recuperative  power  of  a  child's  heart  is  considerable, 
yet  in  various  diseases  there  is  an  increased  tendency  to  heart  compli- 
cations, and  the  child  is  more  liable  to  an  aggravation  of  an  already 
existing  cardiac  affection  than  is  the  adult;  valvular  lesions  are  apt  to 
be  multiple,  pericardial  adhesions  and  cardiac  hypertrophy  frequently 
occur,  and  when  circulatory  disturbance  is  of  severe  type  and  begins 
early  in  life,  growth  and  de^'elopment  are  considerably  retarded. 


ACUTE  ENDOCARDITIS  457 


ACUTE   ENDOCARDITIS. 

The  usual  clinical  classification  of  endocarditis,  myocarditis,  and 
pericarditis  is  based  on  the  most  striking  symptoms  of  each  of  these 
diseases;  but  it  is  well  to  emphasize  the  fact  that  in  any  of  these  con- 
ditions the  child's  entire  heart  is  more  or  less  involved.  Simple  endo- 
carditis may,  in  rare  cases,  be  intra-uterine  in  origin,  and  is  then  usually 
localized  in  the  right  heart.  Postnatal  endocarditis,  in  which 
group  the  majority  of  cases  belong,  seldom  occurs  under  three  or  four 
years  of  age,  because  at  least  75  per  cent,  of  these  cases  are  due  to 
acute  rheumatism  and  chorea,  which  are  both  rare  before  the  fifth 
year.  It  appears  most  frequently  between  the  sixth  and  twelfth  years, 
being  less  common  in  children  of  the  well-to-do,  because  to  some  extent 
preventable. 

While  the  chief  cause  in  all  of  these  cases  is  rheumatism  or  chorea, 
yet  it  not  infrequently  follows  the  infectious  fevers,  especially  scarlet 
fever,  influenza,  and  pneumonia,  also  pleurisy,  bronchitis,  and  pyemic 
conditions.  A  cold,  damp  season,  overexertion  in  anemic  or  rapidly 
growing  children,  shock,  fright,  bad  habits,  severe  digestive  disturb- 
ances, all  favor  the  infection,  especially  when  rapid  growth  and  devel- 
opment at  puberty  severely  tax  an  already  weakened  heart. 

Summarizing,  we  would  say  that  endocarditis  almost  invariably 
appears  as  a  secondary  infection.  Even  when  apparently  primary, 
thorough  investigation  will  prove  that  either  rheumatism  (of  which  a 
cardiac  affection  may  be  the  first  manifestation)  or,  in  rare  cases,  tuber- 
culosis is  the  real  cause.  The  Streptococcus  viridens  is  the  principal 
offender  in  the  smouldering  type  of  endocarditis  (malignant);  but 
staphylococci,  pneumococci,  gonocci,  the  Bacillus  typhosus,  and  the 
Bacillus  coli  communis  are  also  not  infrequently  found. 

Pathology. — The  pathological  lesions  are  mostly  confined  to  the  left 
side  of  the  heart,  involving  the  mitral,  and  much  less  frequently  the 
aortic  valves.  The  hyperemia,  swelling,  inflammation  of  the  cells, 
and  wart-like  excrescences  on  the  free  margins  of  the  thickened 
valves  do  not  essentially  differ  from  those  in  the  adult.  There  is, 
however,  the  difference  that,  when  the  lesions  are  slight,  apparently 
complete  healing  takes  place,  and  the  ulcerative  form  is  extremely 
rare  in  children. 

Symptoms. — These  are  often  remarkably  latent,  the  insidious  onset 
"being  expecially  noteworthy.  There  may  be  vague  pains,  the  so-called 
growing  pains,  or  repeated  attacks  of  angina  and  sore  throat;  but  in 
many  cases  nothing  draws  attention  to  the  diseased  heart  until  breath- 
lessness  disproportionate  to  the  exertion  becomes  noticeable. 

Unless  the  first  symptoms  are  masked  by  an  underlying  disease, 
weakness,  pallor,  failing  appetite,  and  slight  irregular  fever  ensue, 
the  latter  disappearing  when  the  child  rests  in  bed,  and  reappearing 
when  he  gets  up.  After  an  interval,  the  pulse  gradually  grows  rapid, 
irregular,  and  low  in  tension;  subsequently  a  characteristic  blowing 
murmur  makes  its  appearance,   at  first  gradually  increasing,  later, 


458  DISEASES  OF  THE  HEART 

possibly,  diminishing,  being  systolic  in  time  and  frequently  accom- 
panied by  a  thrill. 

Sometimes  a  child  is  brought  to  the  physician  for  symptoms  directly 
traceable  to  the  heart,  i.  e.,  palpitation,  precordial  pain,  and  shortness 
of  breath;  but  whenever  a  stiff  neck,  fleeting  pains  in  the  joints,  and 
so-called  growing  pains  are  complained  of,  it  is  advisable  to  examine 
the  heart. 

In  the  earliest  stages  there  may  be  no  bruit  at  all,  only  very  slight 
increase  in  the  area  of  cardiac  dulness,  and  sometimes  only  a  rapid  and 
irregular  pulse.  A  deep  dulness  should  be  carefully  noted,  because 
dilatation  occurs  easily  and  early;  in  fact,  it  may  be  the  first  or  only 
sign  of  an  affection  of  the  heart. 

Careful  estimation  of  the  size  of  the  heart  is  often  more  enlightening 
than  the  auscultation  of  a  murmur,  but  it  requires  considerable  train- 
ing. In  the  early  stages,  more  or  less  dilatation  of  the  left  side  is  often 
caused  by  toxic  or  inflammatory  changes  in  the  cardiac  muscle  itself; 
but  in  advanced  cases  special  attention  should  be  paid  to  the  right 
border,  because  dilatation  of  the  right  heart,  imless  quickly  relieved 
by  bleeding,  leads  to  lividity,  ascites,  enlarged  liver,  and  extreme 
dyspnea. 

HA-pertrophy  of  the  heart  following  increased  work  against  higher 
pressure  in  the  arterial  system  (especially  in  nephritis)  causes  bulging  of 
the  precordia  more  readily  in  children,  because  the  chest  walls  are  so 
pliable.  In  auscultating,  certain  dilTerences  between  the  signs  in  chil- 
dren and  in  adults  must  be  taken  into  consideration.  Aortic  bruits 
are  very  rare  in  children,  but  do  occur  after  mitral  disease,  the  murmur 
being  systolic  in  time;  later,  when  the  valves  shrink,  a  diastolic  bruit 
may  be  added.  These  murmurs  are  usually  audible  in  the  second  or 
third  interspace  close  to  the  sternum  or  over  the  middle  of  the  sternum. 

The  vast  majority  of  cases  are  due  to  lesions  of  the  mitral  valve, 
manifesting  themselves  by  a  weakened  first  sound  at  the  apex,  which 
becomes  impure,  and  later  may  be  replaced  by  a  bruit  which  is  blowing 
and  soft,  and  may  be  transmitted.  The  second  sound  is  at  first  clear 
and  well  defined,  but  soon  becomes  less  distinct  and  is  reduplicated. 
After  a  time  a  short  puff  develops;  this  is  less  loud  and  shorter  than 
the  systolic  bruit;  thus  we  have  the  well-known  double  murmur  at 
the  apex. 

On  account  of  its  splendid  reserve  power  the  left  heart  easily  over- 
comes the  obstruction,  so  that  for  a  long  time  there  may  be  no  accen- 
tuation of  the  second  pulmonic  sound,  and  no  enlargement  is  demon- 
strable by  percussion  or  the  .r-rays.  H^-pertrophy  and  dilatation  occur 
much  later  in  children  than  in  the  adult.  It  must  be  borne  in  mind 
that  the  clinical  picture  in  infants  differs  considerably,  and  a  diagnosis 
can  seldom  be  made,  chiefly  because  the  infant  or  child  has  always 
had  a  congenital  murmur,  due  to  a  congenital  lesion,  and  the  endo- 
cardial murmur  having  developed  subsequently  and  in  addition  to  the 
congenital  one  it  was,  therefore,  not  noticeable. 

The  course  of  the  disease  shows  great  variations,  and  a  fatal  issue 


ACUTE  ENDOCARDITIS  459 

usually  occurs  in  infants  when  myocarditis  and  pericarditis  compli- 
cate matters,  or  malignant  endocarditis  supervenes.  Acute  endocar- 
ditis ends  in  chronic  valvular  disease  except  in  the  few  cases  in  which, 
within  a  few  weeks,  or  months,  the  murmur  gradually  disappears  and 
the  slightly  affected  valves  to  all  appearances  return  to  the  normal. 
Malignant  endocarditis,  which  is  very  rare  in  children,  is  usually  secon- 
dary to  simple  endocarditis,  or  may  follow  erysipelas,  scarlet  fever, 
septicemia,  and  infection  of  the  oral  cavity  or  of  the  bladder. 

Diagnosis. — ^As  a  rule  the  diagnosis  cannot  be  made  until  the  emboli 
lodging  in  the  kidney,  brain,  intestine,  or  lungs  lead  to  infarcts  or  mul- 
tiple abscesses;  this  is  chiefly  because  cardiac  murmurs  and  dilatation 
often  do  not  appear  until  shortly  before  death,  which  usually  occurs 
within  a  few  weeks.  Clinically,  it  presents  symptoms  of  typhoid 
fever  or  pyemia;  i.  e.,  fever,  prostration,  sometimes  delirium,  an  enlarged 
spleen,  and  meningeal  symptoms. 

The  diagnosis  sometimes  presents  considerable  difficulty.  First, 
accidental  murmurs  must  be  excluded.  Only  when  a  daily  careful 
examination  reveals  a  bruit  of  gradual  onset,  which  is  persistent  and 
more  or  less  uniform  in  character,  may  we  feel  sure  of  existing  endocar- 
ditis. Sometimes  the  symptoms  themselves  may  be  so  marked  as  to 
suggest  the  disease;  but  it  is  only  by  carefully  eliciting  the  physical 
signs  that  the  suspicion  may  be  verified  and  the  diagnosis  confirmed. 
On  inspection  a  rapid  diffuse  apex  beat,  with  sometimes  an  undulating 
motion  over  the  precordia,  may  indicate  cardiac  overactivity.  Pal- 
pation confirms  the  strong,  irregular  heart  action.  On  percussion,  even 
in  the  early  stages,  increased  cardiac  dulness,  especially  on  the  left 
side,  is  not  infrequently  found. 

But  it  is  chiefly  by  auscultation  that  we  are  enabled  to  decide  as 
to  the  character  of  the  murmur,  this  depending  on  the  valve  involved 
and  the  nature  of  the  valvular  lesion.  Examination  of  the  heart  in 
children  is  greatly  simplified  by  the  fact  that  in  them  acute  endocarditis 
is  almost  invariably  limited  to  the  left  side.  The  murmur  may  be 
single  or  multiple,  systolic,  diastolic,  or  presystolic  in  time,  and  soft, 
blowing,  harsh,  grating,  or  rough  in  character.  As  mentioned  before, 
in  the  majority  of  cases  the  mitral  valves  are  involved. 

With  mitral  regurgitation  we  find  a  soft,  blowing,  systolic  murmur 
the  greatest  intensity  of  which  is  toward  the  apex;  it  is  usually  trans- 
mitted outward  to  the  axilla,  and  is  often  distinctly  audible  posteriorly 
between  the  scapula  and  the  spine. 

Mital  stenosis  occasions  a  presystolic  bruit  which  is  not  transmitted, 
but  is  usually  accompanied  by  a  thrill,  and  is  loudest  between  the  mitral 
area  and  the  apex. 

More  often  than  w^ith  a  single  murmur  we  have  to  deal  with  a  double, 
sharp,  presystolic  mitral  murmur,  followed  immediately  by  a  systolic 
murmur  which  almost  drowns  the  first  sound.  The  systolic  murmur 
of  aortic  stenosis  is  loudest  over  the  aortic  area,  is  transmitted  to  the 
carotids,  and,  especially  in  younger  children,  is  audible  over  the  middle 
of  the  sternum.    Aortic  regurgitation  is  characterized  by  a  diastolic 


460  DISEASES  OF   THE  HEART 

iiiuriimr,  heard  principally  between  the  second  and  third  intercostal 
spaces. 

Differential  Diagnosis. — In  children  pericardial  murmurs  are  to  be 
distinguished,  as  in  the  adult,  chiefly  by  the  triangular  area  of  cardiac 
dulness,  the  base  of  the  triangle  corresponding  with  the  apex  beat, 
the  apex  pointing  toward  the  great  vessels,  and  gradually  so  increasing 
that  the  cardiohepatic  angle  and  Traube's  area  below  the  heart  tend 
to  disappear.  Difficulty  in  differentiating  functional  murmurs  is  really 
experienced  only  when  we  are  dealing  with  a  soft,  blowing,  mitral 
lesion.  The  accidental  murmur  in  these  cases  is  inconstant,  changes 
more  or  less,  may  even  disappear  on  change  of  position,  and,  as  a  rule, 
is  not  distinctly  transmitted.  Under  proper  care  it  usually  passes 
away  after  a  short  time.  There  should  be  no  accompanying  cardiac 
hypertrophy. 

Prognosis. — The  prognosis  of  endocarditis  is  always  grave.  The  dis- 
ease is  usually  fatal  in  infants,  the  danger  to  life  in  older  children  being 
rather  remote.  Some  may  remain  in  a  more  or  less  invalid  condition, 
but  the  case  does  not  necessarily  go  from  bad  to  worse;  in  fact,  the 
greater  number  recover  more  or  less  completely  if  treated  eflficiently 
from  the  beginning. 

But  in  some  cases,  even  with  the  best  of  care,  the  valves  are  impaired 
for  life,  and  as  long  as  evidence  of  rheumatism  persists  there  is  danger 
of  further  cardiac  mischief.  Considering  that  the  tendency  to  rheuma- 
tism and  chorea  is  greatest  between  the  fifth  and  twelfth  years,  the 
earlier  the  first  attack  of  heart  disease  occurs,  the  greater  is  the  prob- 
ability that  the  condition  will  be  aggravated  by  subsequent  attacks; 
consequently,  after  puberty  the  chances  for  comparative  comfort 
steadily  improve. 

Pericarditis  is  the  one  complication  most  to  be  feared;  many  cases 
end  fatally  within  a  month  or  two,  and  all  lead  to  adhesions  which  grad- 
ually cause  hypertrophy  and  dilatation,  and  end  in  ruptured  compen- 
sation. On  the  other  hand,  it  cannot  be  too  strongly  emphasized  that 
loud  murmurs,  unquestionably  of  rheumatic  origin,  may  disappear 
completely,  and  thus  they  warrant  a  hopeful  outlook,  especially  when 
of  recent  origin;  even  in  advanced  cases  we  may  hope  for  considerable 
improvement.  Ulcerative  endocarditis,  fortunately  extremely  rare 
in  children,  probably  in  all  cases  ends  fatally  within  a  few  weeks. 

Treatment. — It  is  the  mild  case  that  presents  the  most  serious  prob- 
lem, because,  owing  to  the  lack  of  objective  symptoms,  the  parents 
are  not  easily  conviced  of  the  gravity  of  the  disease.  The  remedy 
par  excellence  is  rest,  and  rest  in  bed.  Whether  we  are  dealing  with  a 
mild  or  a  severe  case,  our  chief  aim  is  to  tax  the  heart  as  little  as  pos- 
sible. No  strain  or  stress  of  any  kind  should  be  allowed;  even  the  use 
of  the  arms  and  legs  had  better  be  restricted,  especially  in  the  first 
stage,  which  is  the  time  when  most  damage  is  done.  This  should  be 
kept  up  for  weeks  until  the  heart  becomes  more  regular,  less  excitable, 
and  can  endure  slight  exercise  tests,  and  the  treatment  must  be  insisted 
upon  in  spite  of  the  protests  of  both  parents  and  children. 


ENDOCARDITIS  OR  ACQUIRED   VALVULAR  DISEASE       461 

In  this  connection  it  may  not  be  amiss  to  emphasize  the  importance 
of  sleep  as  the  best  means  of  securing  rest.  It  may  even  be  necessary 
to  resort  to  drugs,  as  codein  or  bromide,  for  this  purpose,  especially 
in  the  more  advanced  stages  of  the  disease.  Ordinarilj^  a  comfortable 
bed,  a  quiet,  darkened  room,  and  a  tactful  nurse  are  sufficient;  in  order 
to  avoid  too  frequent  disturbance  of  the  child,  it  is  advisable  to  give 
medicine  and  food  at  the  same  time. 

An  ice-bag,  half-filled  with  shaved  ice  and  applied  over  the  pre- 
cordium  usually  quiets  and  slows  the  heart.  Children,  however,  do 
not  always  take  kindly  to  this  measure,  and  if  it  makes  them  irritable 
or  restless  it  had  better  be  removed  for  a  short  time,  and  then  applied 
again.    Of  course,  it  cannot  be  used  on  the  infant. 

Diet. — Xo  tea  or  coffee  should  be  given.  In  the  beginning  the  child's 
food  should  be  mainly  liquid,  varied  by  the  addition  of  gruels,  broths, 
and  custards — not  a  strictly  milk  diet,  of  which  the  child  soon  becomes 
surfeited,  and  which  it  refuses,  consequently  is  apt  to  suffer  from  under- 
nourishment. 

With  progressive  improvement,  eggs,  bread  and  butter,  and  stewed 
fruits  may  be  added ;  later  poultry,  fish,  and  simple  puddings  provided 
they  do  not  distend  the  stomach.  Saline  laxatives  may  be  necessary 
to  insure  a  daily  bowel  movement.' 

Drugs. — Salicylates  combined  with  double  their  amount  of  alkali, 
or  aspirin,  which  is  less  irritable  to  the  stomach,  should  be  given  when- 
ever there  is  evidence  of  rheumatism  or  the  least  suspicion  of  endocar- 
ditis, unless  the  latter  can  be  traced  to  diphtheria  or  an  infectious  fever. 
This  medication  should  be  kept  up  until  the  fever  and  rapid  cardiac 
action  abate,  and  even  then  small  doses  may  be  given  at  short  intervals. 

It  is  advisable  to  continue  this  medication  for  at  least  a  month, 
and  afterward  to  repeat  it  for  one  week  in  every  month  to  ward  oft' 
any  possibility  of  a  recurrence,  especially  when  there  are  signs  of  ton- 
sillitis or  other  manifestations  of  a  rheumatic  tendency.  Ordinarily  dig- 
italis can  be  dispensed  with;  when,  in  severe  cases,  stimulation  seems 
imperative,  camphor  and  caffeine  are  preferable,  while  for  excitement 
and  restlessness  five  to  ten  grain  doses  of  sodium  bromide  and  | 
grain  of  codeine,  p.  r.  n.,  are  permissible  and  even  advisable. 

If,  during  convalescence,  the  pulse  is  well  below  100,  the  child  may 
gradually  be  propped  up  in  bed  for  an  hour  a  day  and,  if  the  heart  can 
stand  it,  very  cautiously  gotten  up  in  a  reclining  chair.  So,  little  by 
little,  and  chiefly  guided  by  the  heart  action,  the  child  raay  increase 
its  exercise  every  day,  and  gradually  resume  its  normal  life.  Diseased 
tonsils  and  adenoids  should  be  removed. 

CHRONIC   ENDOCARDITIS    OR    ACQUIRED    VALVULAR    DISEASE. 

Valvular  defects  usually  follow  an  endocardial  infection  which,  in 
the  majority  of  cases,  is  rheumatic  in  origin;  therefore  they  rarely 
originate  before  the  third  year,  but  almost  always  appear  after  the 
fifth.    There  is,  of  coiu'se,  no  definite  time  limit  for  the  acute  condition, 


462  DISEASES  OF   THE  HEART 

which,  indeed,  may  gradually  run  into  the  chronic.  It  is  true  that  the 
preceding  acute  endocarditis  is  often  either  not  suspected  or  not 
diagnosed;  nevertheless,  the  most  important  etiological  factor  is  usually 
a  rheumatic  affection;  arteriosclerosis  and  poisons,  such  as  alcohol  or 
syphilis,  being  rarely  the  cause  of  valvular  disease  before  puberty. 

Symptoms. — These  may  make  their  appearance  very  insidiously, 
and  depend  in  some  degree  upon  the  character  and  the  site  of  the  lesion. 
They  may  be  latent  for  years,  the  child  looking  well,  appearing  vigorous 
and  showing  good  powers  of  endurance  up  to  puberty,  the  cardiac  de- 
fect often  being  discovered  accidentally  during  a  routine  examination 
of  the  heart.  Some  patients  are  rather  irritable,  easily  tired,  pale 
at  times,  and  complain  of  headache  after  mental  or  physical  exertion. 
Other  subjective  signs  are  slightly  disturbed  compensation,  or  nose- 
bleed which  may  be  repeated  and  violent  and  accompanied  or  followed 
by  headache,  ringing  of  the  ears,  dizziness  which  is  increased  on  stoop- 
ing, or  shortness  of  breath  on  climbing  or  running  upstairs,  and 
persisting  for  some  time  after  exertion. 

Children  very  rarely  complain  of  cardiac  palpitation;  but  a  stubborn 
catarrh  of  the  respiratory  passages,  an  irritating  little  cough,  coryza, 
and  swollen  turbinals,  diminished  appetite,  vague  pains  in  the  back 
and  nape  of  the  neck,  may  all  indicate  an  undiscovered  cardiac 
affection. 

^Yith  the  advent  of  disturbed  compensation  these  symptoms  becom.e 
exaggerated  and,  in  addition,  are  associated  with  a  consequent  mechani- 
cal impairment  of  the  circulation  as  showm  by  cyanosis  of  the  lips, 
the  fingers,  and  the  toes,  enlarged  veins  of  the  neck,  scalp,  and  thorax, 
enlarged  and,  possibly,  tender  liver,  edema  of  the  limbs  and  of  the 
peritoneal,  pleural,  and  pericardial  cavities.  Dyspeptic  symptoms 
are  conspicuous  in  all  of  these  cases. 

Physical  Sigrs. — In  valvular  disease  of  the  heart  in  children  the 
physical  signs  are  for  the  most  part  identical  with  those  in  the  adult, 
although  children  do  not  usually  complain  of  palpitation,  the  cardiac 
impulse  being  visibly  and  palpably  strong.  When  the  lesions  are  severe 
the  bulging  of  the  precordia  is  the  more  m.arked  the  younger  the  child. 
Often  no  such  bulging  is  found;  for  years  there  may  be  no  perceptible 
difference  on  percussion;  the  area  of  dulness  may  be  only  slightly 
extended  to  the  left,  as  revealed  by  .r-ray  examination. 

Murmurs. — Organic  murmurs  are  usually  distinct,  often  loud  and 
rough,  especially  over  the  apex,  and  they  are  heard  not  only  over  their 
respective  areas,  but  very  often  in  older  children,  always  in  younger 
ones,  also  in  the  back  between  the  shoulder  blades  and  at  the  angle 
of  the  scapula.  Only  when  the  compensation  is  ruptured  is  the  area 
of  cardiac  dulness  greatly  extended  on  the  right  side,  this  suggesting 
pericardial  effusion  for  which,  in  fact,  it  is  often  mistaken. 

The  Piilse. — ^If  the  cardiac  muscle  is  involved,  we  m.ay  occasionally 
have  arrh\'thmia.  The  special  symptoms  of  disease  of  the  diiferent 
valves  are,  generally  speaking,  similar  to  those  in  the  adult;  but  it 
must  be  emphasized  that  the  most  common  clinical  variety  is  mitral 


ENDOCARDITIS  OR  ACQUIRED   VALVULAR  DISEASE       463 

disease,  which  before  puberty  occurs  about  twenty  times  more  fre- 
quently than  do  aortic  valvular  defects.  Mitral  insufficiency  often 
appears  alone,  and  represents  the  com.mon  form  in  early  life.  The 
murmur  is  more  or  less  synchronous  with  the  first  sound,  is  best  heard 
over  the  apex,  and  is  transmitted  to  the  left.  The  m.urm.ur  is  more  or 
less  diffuse,  accompanied  by  an  accentuation  of  the  second  pulmonic 
sound,  and  the  signs  of  hypertrophy. 

Although  the  two  latter  points  are  important  in  differentiating 
organic  from  merely  functional  murm.urs,  it  must  be  stated  that  they 
m.ay  not  appear  for  quite  a  little  time.  Mitral  stenosis  usually  com- 
plicates mitral  insufficiency,  but  may  not  be  detected  until  years 
after  the  appearance  of  the  first  lesion,  while  as  an  isolated  or  primary 
lesion  it  is  hardly  ever  found  before  puberty.  The  bruit  may  be  alm.ost 
inaudible  or  may  become  noticeable  only  after  exertion;  as  a  rule  it  is 
rough,  terminates  sharply  with  the  first  sound  (presystolic),  is  loudest 
at  the  apex,  and  strictly  localized. 

Aortic  disease  is  rarely  observed  before  the  tenth  or  twelfth  year, 
insufficiency  and  stenosis  appearing  at  about  the  same  time.  It  is 
usually  of  serious  import,  and  may  cause  sudden  death. 

Stenosis  is  characterized  by  a  systolic  murmur,  heard  chiefly  at  the 
right  border  of  the  sternum  and  second  interspace,  and  transmitted 
upward  into  the  carotids.  The  second  aortic  sound  is  weak.  With 
aortic  stenosis  there  is  necessarily  present  hypertrophy  of  the  heart, 
although  this  is  not  as  marked  as  in  aortic  insufficiency.  If  there  is  no 
hypertrophy  the  murmur  is  probably  an  accidental  (hemic)  one, 
therefore  it  would  necessitate  a  revision  of  the  diagnosis.  Aortic 
insufficiency  causes  a  prolonged  diastolic  murmur,  coincident  with  or 
replacing  the  second  sound.  It  is  loudest  at  the  left  side,  and  is  trans- 
mitted along  the  sternum  toward  the  apex;  associated  with  it  is  m.ost 
marked  cardiac  hypertrophy  which,  of  course,  is  especially  noticeable 
when  beginning  failure  of  compensation  causes  dilatation  of  the  left 
ventricle.    There  is  also  intense  throbbing  of  the  carotids. 

Tricuspid  insufficiency  is  usually  caused  by  dilatation  of  the  right 
ventricle  after  a  serious  mitral  lesion.  It  gives  rise  to  a  systolic  murmur, 
the  greatest  intensity  of  which  is  over  the  lower  part  of  the  sternum. 
The  jugular  veins  standout  prominently,  and  m.ay  show  systolic  pulsation. 

As  regards  the  future  course  of  cardiac  disease,  there  is  no  doubt 
that  children  m.ay  recover  from,  mitral  insufficiency,  even  though  we 
have  been  careful  to  classify  as  such  only  those  cases  in  which  the  bruit 
appears  gradually  after  an  acute  rheumatic  infection,  and  persists 
for  months,  or  even  for  years.  In  the  m.ajority  of  cases,  however,  the 
disease  remains  m.ore  or  less  latent  until  puberty.  There  are  cases  in 
which  serious  manifestations  appear  after  years  of  apparent  latenc}', 
this  probably  being  due  to  the  fact  that  the  cardiac  muscle  gradually 
becom.es  weaker  and  can  no  longer  continue  to  compensate,  i.  e., 
beca,use  of  the  necessarily  increased  amount  of  work,  or  because  a 
fresh  endocarditis  is  superimposed  upon  the  old  lesion. 

In  the  rare  cases  where  death  occurs  in  a  comparatively  short  time 


464  DISEASES  OF   THE  HEART 

(within  a  few  months  or  years)  we,  no  doubt,  are  deahng  with  more  tlian 
a  valvular  defect;  in  all  probability  with  pericarditis  or  myocarditis. 
In  a  general  way,  we  may  say  that  in  children  a  purely  valvular  defeat 
can  be  far  better  compensated  and  for  a  longer  time  than  in  the  adult. 
On  the  other  hand,  when  failure  of  compensation  appears  the  end  is 
close  at  hand. 

Diagnosis. — In  m.aking  a  diagnosis  of  organic  heart  disease  in 
children  one  cannot  be  too  cautious.  The  sam.e  underlying  principles 
as  in  the  adult  must  be  our  guide.  But  there  are  added  difficulties 
to  be  overcome  in  eliminating  the  different  varieties  of  accidental 
m.urmurs,  and  it  is  som.etim.es  alm.ost  im.possible  correctly  to  diagnose 
mitral  insufficiency  in  children  between  five  and  fifteen  years  of  age. 
On  the  one  hand,  in  organic  mitral  insufficiency,  enlargement  of  the 
left  ventricle  and  accentuation  of  the  second  pulmonic  sound  may  be 
absent  for  a  long  time;  yet  when  the~systolic  murmur  is  not  perm.anent, 
is  loudest  in  the  m.itral  area,  is  equally  audible  whether  the  patient  is 
lying  down  or  sitting  up,  and  is  associated  with  a  heaving  apex  beat 
due  to  hypertrophy  of  the  left  ventricle,  it  cannot  be  clearly  distin- 
guished from,  that  due  to  mitral  regurgitation. 

Furthermore,  it  m.ust  be  differentiated  in  those  cases  of  defective 
intraventricular  septum  when  only  the  upper  membranous  part  of 
the  septum  is  patent.  In  these  cases  there  is  a  loud  systolic  murm.ur, 
audible  over  the  whole  heart  (which  m.ay  or  m.ay  not  be  hypertrophied) , 
the  murm.ur  being  most  intense  in  the  third  left  interspace,  is  trans- 
mitted to  the  back  but  not  to  the  carotids,  and  m.ay  or  m.ay  not  be 
accompanied  by  an  accentuated  second  pulm.onic  sound.  Finally, 
it  is  well  not  to  overlook  the  fact  that  in  anem.ic  school  children  absolute 
cardiac  dulness  is  not  infrecpiently  increased  on  account  of  the  insuffi- 
cient expansion  of  the  margin  of  the  lungs  o\'erlying  the  heart.  If, 
in  such  a  case,  a  hemic  murm.ur  is  audible,  the  affection  can  easily 
be  m.istaken  for  organic  disease. 

Treatment. — Prophylaxis  practically  resolves  itself  into  the  most 
careful  treatment  of  any  manifestation  of  rheum.atism.,  including  sore 
throat  or  chorea,  also  the  observance  of  cardiac  hygiene,  with  rest, 
and  the  use  of  the  salicylates.  Considering  the  fact  that  these  rheu- 
matic affections  have  a  tendency  to  recur,  a  weekly  course  of  salicylates 
and  alkalies  once  a  month,  or  once  in  two  months,  seems  a  wise  pre- 
caution. Whether  we  adopt  passive  treatment — that  is,  restriction 
of  the  ordinary  routine  of  life — or  active  measures  by  drugs,  etc., 
nothing  should  be  done  until  the  diagnosis  is  definitely  settled. 

As  long  as  compensation  is  maintained  satisfactorily,  no  special 
treatment  is  necessary.  The  child  need  not  be  frightened,  but  the 
parents  should  be  told  of  the  condition  so  that  they  m.ay  guard  against 
any  excessive  physical  exercise,  cycling,  football,  baseball,  rowing, 
etc.;  alcohol,  tea,  and  coffee  should  be  prohibited.  AYhile  the  whole 
life  should  thus  be  regulated,  and  the  child  carefully  watched,  there  is 
no  reason  why  it  should  be  condemned  to  a  life  of  in\'alidism;  and  the 
less  interference  the  better  for  the  patient. 


ACUTE  PERICARDITIS  465 

Careful  regulation  of  the  exercise  taken  by  the  child  is  necessary 
from  time  to  time,  the  physician  being  guided  by  the  symptoms  and 
physical  signs  of  cardiac  disease.  This  will  enable  him  to  decide  upon 
the  proper  management  of  the  individual  case.  All  possibility  of 
reinfection  must,  as  far  as  possible,  be  prevented  by  avoiding  exposure 
to  cold  and  wet,  and  by  having  diseased  tonsils,  the  teeth,  the  kidneys, 
or  any  general  disturbances  of  the  alimentary  tract,  promptly  treated. 

Country  life,  especially  in  a  warm  and  dry  climate,  is  very  beneficial, 
and  a  gradual  hardening  of  the  body  against  changes  of  temperature 
is  to  be  recommended.  Woolen  undergarments  should  be  worn, 
especially  in  the  cold  season.  As  soon  as  cardiac  failure  appears,  rest 
becomes  imperative,  and  such  other  measures  or  treatment  should 
be  applied  as  will  improve  the  functional  power  of  the  left  ventricle. 
All  nervous  strain  should  be  removed,  and  rest  for  the  heart  and 
refreshing  sleep  secured  by  the  judicious  use  of  the  bromides,  morphine, 
or  codein,  and  a  carefully  regulated  diet;  for  the  first  eight  days  a 
somewhat  restricted  milk  diet  is  probably  the  best.  If  these  measures 
do  not  avail,  it  is  then  tim.e,  just  as  in  the  adult,  to  use  digitalis,  or 
any  of  the  other  heart  stimulants,  such  as  camphor,  caffeine,  adrenaline, 
or  morphine. 

ACUTE  PERICARDITIS. 

There  is  a  mild  form  of  pericarditis  marked  by  a  slight  deposition 
of  fibrin  or  a  slightly  increased  amount  of  pericardial  fluid.  This  may 
occur  in  the  course  of  infectious  diseases,  and,  as  a  rule,  is  not  diagnosed 
unless  it  goes  on  to  suppuration,  as  sometimes  happens  in  scarlet  fever 
and  m.easles.  But  the  m.ore  severe  form  of  pericarditis  is  of  real 
clinical  importance.  It  occurs  in  general  sepsis  of  the  newborn  and 
in  young  infants,  and  is  usually  purulent  in  character.  Between  the 
second  and  the  seventh  years  the  infection  spreads  from  an  adjacent 
focus  in  the  lungs  and  pleurae,  and  is  then  usually  caused  by  the 
pneumococcus.  After  this  age  most  pericardial  effusions  are  due 
either  to  tuberculosis  or  to  repeated  rheumatic  infections.  In  these 
cases  the  functional  capacity  of  the  heart  is  threatened  by  adhesions 
which  are  liable  to  form  when  the  effusion  becomes  absorbed. 

Summarizing,  we  would  say  that  rheumatic  infection  is  by  far  the 
commonest  cause  of  pericarditis  in  children;  but  we  must  not  lose 
sight  of  the  fact  that  this  pericarditis  is  always  associated  with  endo- 
carditis and  more  or  less  involvement  of  the  cardiac  muscle.  While 
often  obscured  by  the  primary  disease,  that  is,  by  sepsis,  pleurisy, 
or  pneumonia,  the  clinical  picture  of  rheumatic  endocarditis  is  clear- 
cut  except  when  another  underlying  etiological  factor  (such  as  endo- 
carditis or  arthritis,  and  in  older  children  chorea)  produces  additional 
symptoms. 

Symptoms. — x^cute  pericarditis  often  begins  with  vomiting,  fever, 

headache,  loss  of  appetite,  and  restlessness,  soon  followed  by  pallor 

of  the  face,  and  later  by  lividity  of  the  mucous  membrane.    The  patient 

is  short  of  breath,  and  a  frequent,  dry,  irritating,  little  cough  often 

30 


466  DISEASES  OF  THE  HEART 

interferes  with  sleep.  Pain  over  the  precordium,  or  a  sense  of  oppres- 
sion, is  not  always  complained  of,  even  when  well-marked  friction 
sounds  are  heard. 

The  pulse  usually  becomes  more  rapid  and  w^eak.  Upon  examina- 
tion we  may  hear  slight  friction  sounds  which  in  the  beginning  m.ay 
resemble  a  soft,  blowing,  endocardial  bruit;  but  these  sounds  are 
variable,  usually  localized  at  the  base,  and  sometimes  increased  by 
pressure  with  the  stethoscope.  The  well-known  triangular  area  of 
increased  cardiac  dulness  with  its  apex  toward  the  aortic  area  bears 
witness  to  the  progressive  accumulation  of  pericardial  fluid.  Traube's 
space  is  obliterated,  and  the  cardiohepatic  angle  as  well,  because  the 
exudate  collects  somewhat  more  to  the  right  and  left  of  the  apex. 

The  impulse  often  persists  in  palpable  form  for  a  long  time,  and  the 
heart  sounds  become  m.ore  and  more  distant.  The  greater  the  amount 
of  exudate  the  greater  the  tax  on  the  heart,  which  is  manifested  by  a 
pulse  rate  of  140  to  180,  or  even  190.  Cyanosis,  the  fulness  of  the  large 
cervical  veins,  marked  swelling  of  the  liver,  and  general  edema  are 
all  due  to  congestion. 

When  no  absorption  takes  place,  the  feeling  of  oppression  and  the 
dyspnea  continue  to  increase,  and  lead  to  cardiac  weakness  which  ends 
fatally  within  a  short  time.  Even  absorption  of  the  fluid  does  not 
necessarily  indicate  a  cure,  because  the  resulting  adhesions  of  the 
pericardium  considerably  embarrass  the  heart,  and  quickly  lead  to 
hypertrophy.  Death  may  be  postponed  for  only  a  few  years,  especially 
when,  as  is  often  the  case,  there  is  a  complicating  endocarditis. 

Diagnosis. — As  in  the  adult,  the  diagnosis  rests  upon  the  gradual 
increase  of  the  triangular  area  of  dulness,  which  obliterates  the  cardio- 
hepatic angle  and  Traube's  semilunar  space.  The  fact  that  the  area 
of  absolute  cardiac  dulness  increases  or  extends  more  rapidly  than  that 
of  relative  dulness  is  a  decided  help.  While  a  large  effusion  can  hardly 
be  overlooked  unless  there  be  an  accompanying  left-sided  pleural 
effusion,  it  is  often  difficult  definitely  to  diagnose  a  sm.all  effusion, 
especially  in  children;  often  the  .r-rays  alone  can  decide  this  question. 
The  .r-ray  picture  enables  one  also  to  dift'erentiate  these  cases  from 
cardiac  dilatation.  When  it  is  a  question  in  a  given  case  whether  the 
exudate  is  serous  or  purulent  in  character,  a  distinct  increase  in  leuko- 
cytes favors  the  latter. 

Prognosis  and  Course. — These  vary  according  to  the  individual 
conditions.  Purulent  cases,  unless  saved  by  surgical  intervention, 
are  likely  to  end  fatally,  while  the  non-purulent,  which  are  chiefly 
of  rheumatic  origin,  offer  a  good  prognosis  as  to  life,, but  not  as  to 
complete  recovery ;  since,  even  though  the  fluid  be  absorbed,  adhesions 
between  the  two  layers  and  complete  obliteration  of  the  pericardial 
sac  occur  much  more  often  in  children  than  in  adults,  and,  by  crippling 
the  heart  permanently,  mark  the  beginning  of  a  life  of  invalidism 
which  may  be  more  or  less  prolonged. 

In  mild  cases,  the  outcome  depends  largely  upon  the  management. 
As  regards  the  duration  of  the  acute  symptoms,  one  week  is  the 


ADHERENT  PERICARDITIS  467 

minimum  in  m.ild  cases,  while  in  severe  ones  they  may  last  much 
longer;  the  average  time  being  about  three  weeks.  Recovery  at 
best  is  slow,  and  only  partial. 

Treatment. — The  prophylactic  measures  discussed  under  endocarditis 
are  applicable  here  also,  especially  precautions  against  recurrent  attacks 
of  rheumatic  fever,  the  removal  of  diseased  tonsils,  etc.  The  first 
principle  in  the  management  of  the  patient  during  an  attack  is  absolute 
rest  in  bed.  The  child  should  be  allowed  to  do  nothing  that  others 
can  do  for  him,  and  should  not  get  up  until  he  can  do  so  without  any 
symptoms  of  heart  strain. 

In  cases  of  rheumatic  origin,  sodium  salicylate  should  be  adminis- 
tered, combined  with  a  double  quantity  of  bicarbonate  of  soda — 
5  grains  of  the  salicylate  and  10  grains  of  the  soda  every  three  hours 
to  a  child  of  five  years.  For  delicate  children  and  those  who  can- 
not tolerate  the  salicylates,  aspirin  is  preferable,  in  doses  of  8  to  10 
grains,  three  times  a  day,  for  a  child  ten  years  of  age. 

The  early  and  intermittent  use  of  an  ice-bag  seems  to  quiet  the  heart 
action  and  reduce  the  fever.  It  should  be  continued  only  until  the 
acute  symptoms  begin  to  subside;  later,  warmth  seems  preferable. 
In  my  experience  counterirritants  and  blisters  are  of  little  use,  therefore 
not  recommended. 

The  diet  should  be  simple,  nutritious,  light,  and  somewhat  restricted 
during  the  acute  stage,  consisting  principally  of  cereals,  milk,  eggs, 
custards,  and  toast. 

Extreme  rapidity  of  the  pulse  may  be  counteracted  by  the  judicious 
use  of  tincture  of  strophanthus,  which  is  superior  to  digitalis  inasmuch 
as  it  does  not  so  easily  derange  the  stomach.  When  the  patient  is 
restless  or  distressed,  morphia,  in  xo  to  -V  of  a  grain  doses,  relieves 
pain  and,  at  the  sam.e  time,  acts  as  a  cardiac  sedative.  In  the  very 
young,  sodium  bromide  should  first  be  tried;  if  it  has  no  effect,  pare- 
goric should  be  given  in  doses  of  10  to  20  drops  at  three  hour  intervals, 
p.  r.  n.,  and  in  children  above  two  years  of  age  |  to  ^V  of  a  grain  of 
codein  (not  more  than  three  doses  in  the  twenty-four  hours) . 

Excessive  exudate  may  call  for  surgical  intervention.  This,  in  fact, 
offers  the  only  chance  in  an  otherwise  hopeless  case  of  purulent  effusion. 
When  we  are  dealing  with  a  serous  effusion,  a  mere  puncture  of  the 
pericardial  sac  may  be  sufficient.  This  puncture  is  usually  m.ade  by 
m.eans  of  a  small  aspirating  trocar,  either  in  the  fifth  right  interspace, 
one  and  one-half  inches  to  the  right  of  the  right  sternal  border,  or  in 
the  fourth  or  fifth  left  interspace,  at  the  sam.e  distance  from  the  left 
sternal  border,  thus  avoiding  the  internal  m.amm.ary  artery.  After 
the  trocar  is  introduced,  the  fluid  is  allowed  to  drain  out  slowly. 

ADHERENT  PERICARDITIS. 

Adherent  pericarditis  is  not  unusual  after  the  eighth  year,  and  may 
follow  a  single  or  repeated  attacks  of  pericarditis  (usually  rheumatic 
in  origin),  although  the  preceding  disease  may  not  have  been  recog- 


468  DISEASES  OF   THE  HEART 

nized.  The  adhesions  left  after  absorption  of  the  exudate  greatly 
hamper  the  heart,  and  thus  give  rise  to  hypertrophy  and  to  dilatation 
of  both  ventricles. 

Morbid  Anatomy. — The  pericardium  may  be  greatly  thickened, 
or  both  of  its  layers,  the  parietal  and  visceral,  may  become  adherent, 
thus  partially  or  completely  obliterating  the  pericardial  sac.  Some- 
times even  external  adhesions  form  and  bind  the  heart  to  the  chest 
wall,  the  pleurse,  the  ro.ediastinal  structures,  or  the  diaphragm.  When 
tuberculosis  is  the  etiological  factor,  caseous  deposits  and  tubercles  are 
found.  Other  changes  are  usually  also  present,  especially  a  low-grade 
myocarditis  which  causes  increasing  dilatation  and  weakening  of  the 
cardiac  muscles. 

Symptoms. — These  are  often  latent,  and  the  condition  may  rem.ain 
unrecognized  in  those  cases  where  m.urm.urs  of  valvular  lesions  or  the 
symptoms  of  an  underlying  constitutional  disease  obscure  the  clinical 
picture.  As  a  rule  the  symptoms  are  those  of  gradually  increasing 
insufficiency,  -especially  a  rapid,  weak,  irregular  pulse,  easily  affected 
by  exertion,  which  also  causes  dyspnea  and  cardiac  distress,  finally 
leading  to  gradual  failure  or  to  sudden  death.  The  apex  beat  is  diffuse, 
often  feeble,  or  even  absent. 

The  characteristic  sign  of  adhesions  between  the  pericardium  and 
the  chest  wall  is  a  systolic  retraction  of  the  latter  at  or  near  the  apex 
of  the  heart.  This  must,  however,  be  carefully  differentiated  from,  the 
systolic  sinking  of  the  intercostal  spaces  with  marked  apex  beat  which 
is  found  in  cardiac  hypertrophy. 

Almost  equally  characteristic  is  a  diastolic  rebound  of  the  inter- 
costal spaces  over  the  greater  parts  of  the  pericardium,  associated 
with  diastolic  collapse  of  the  jugular  vein,  and  immobility  of  the  heart — 
the  position  of  the  apex  and  the  cardiac  dulness  in  general  not  changing 
with  the  position  of  the  child. 

All  other  symptoms,  such  as  dyspnea,  precordial  distress,  cyanosis, 
small  pulse,  and  signs  of  hypertrophy  and  dilatation,  may  also  be  due 
to  endocarditis  or  myocarditis,  and  can  be  regarded  as  suspicious  of 
obliterative  pericarditis  only  when  there  is  a  history  of  a  preceding 
attack  of  pericarditis,  from  which  the  patient  has  not  recovered. 

Percussion  proves  that  the  cardiac  dulness  is  increased  in  all 
directions.  The  children  are  sickly;  they  do  fairly  well  as  long  as 
they  stay  in  bed,  although  the  small,  rapid  pulse,  and  difficult  respi- 
ration on  the  least  exertion,  show  their  true  condition.  As  soon  as 
they  get  up,  however,  they  are  easily  fatigued,  become  cyanotic  and 
dyspneic,  and  willingly  take  to  bed.  Sometimes  the  child  may  show 
considerable  improvement  for  a  while,  then  the  heart  again  breaks 
down,  with  accompanying  fever,  bronchitis,  pleurisy,  and  subsequently 
edema.  The  liver  and  spleen  enlarge,  ascites  develops,  and  sooner  or 
later  death  ensues. 

Diagnosis. — The  diagnosis  is  often  merely  a  surmise  when  neither 
the  friction  sound  nor  the  exudate  of  preceding  acute  pericarditis 
has   been  observed.       It   may,  however,   be   correctly    made   when 


MYOCARDITIS  469 

symptoms  of  myocardial  insufficiency  follow  an  acute  attack  of  per- 
icarditis. Although  .T-ray  examination  may  be  a  valuable  aid,  diagnosis 
is  often  very  difficult,  especially  in  the  absence  of  the  characteristic 
sign  of  systolic  chest  retraction.  Adherent  pericarditis  in  its  later 
stages,  characterized  by  lost  liver  and  ascites,  can  be  differentiated 
from  cirrhosis  of  the  liver  by  the  concomitant  cyanosis,  the  small, 
rapid  pulse,  and  extreme  dyspnea. 

Prognosis. — This  is  unfavorable  in  all  but  the  mildest  cases,  death 
invariably  occurring  after  a  few  months  or  years.  For  this  reason  all 
treatment  is  unsatisfactory,  and  must  be  symptomatic,  as  in  myo- 
cardial insufficiency.  On  account  of  the  accompanying  myocardial 
degeneration,  even  digitalis  is  unavailing.  Embarrassing  pleural  or 
abdominal  effusions  should  be  removed  by  puncture.  Placing  the 
child  on  a  nourishing  diet,  giving  it  good  general  care,  and,  perhaps, 
injections  of  fibrolysin,  are  all  that  can  be  done  to  insure  the  patient's 
temporary  comfort.  Operation  with  a  view  to  freeing  the  external 
adhesions  of  the  heart  can  hardly  be  considered  in  childhood. 

MYOCARDITIS. 

Myocarditis  is  rarely  a  primary  disease.  In  most  cases  designated 
as  such  it  is  probable  that  the  underlying  affection  has  escaped  detec- 
tion. The  acute  form,  usually  of  mild  degree,  and  due  to  the  action  of 
bacterial  toxins,  frequently  accompanies  the  acute  infectious  diseases, 
especially  diphtheria,  scarlet  fever,  and  sepsis,  also  typhoid  fever, 
influenza,  whooping-cough,  and  pneumonia. 

These  toxins  appear  to  affect  chiefly  the  nerves  and  muscle  tissues, 
giving  rise  to  parenchymatous  degeneration,  while  bacteria,  such  as 
streptococci,  staphylococci,  and  pneumococci,  which  invade  the  heart 
by  way  of  the  blood  stream,  seem  to  attack  the  interstitial  tissues. 
As  emphasized  elsewhere  (page  457),  the  inflammation  of  endocarditis 
or  pericarditis  usually  extends  more  or  less  to,  and  affects,  the  myo- 
cardium, thus  producing  a  real  carditis,  which  affects  the  whole 
organ.  The  chronic  form  is  much  more  rare  in  children  than  in  adults, 
and  causes  no  arterial  degeneration. 

Pathology. — The  cardiac  muscle  is  pale  in  color,  soft,  and  somewhat 
friable.  Seen  under  the  microscope,  the  changes  are  very  distinct, 
round-celled  infiltration  and  granular  hyaline  fatty  degeneration  of 
the  muscle  fiber  being  apparent.  This  explains  why  the  weakened 
heart  muscle  so  readily  undergoes  dilatation. 

Symptoms. — There  may  be  no  appreciable  symptoms,  and  death 
may  occur  very  suddenly.  When  the  affection  develops  during  the 
course  of  an  infectious  disease,  the  symptoms  are  usually  indefinite, 
and  become  more  distinct  only  during  convalescence.  At  this  period 
the  clinical  picture  of  the  acute  infectious  disease  masks  wholly  or 
in  part  the  symptoms  and  physical  signs  of  the  associated  myocarditis. 
The  first  and  most  characteristic  sign  is  a  persistently  irregular  pulse, 
either  more  rapid  or  slower  than  normal.    This  is  especially  significant 


470  DISEASES  OF   THE  HEART 

during  or  after  diphtheria,  scarlet  fever,  or  pneumonia.  Later  a 
systoHc  m.urmur  is  heard  over  the  apex,  the  apex  beat  becomes  more 
feeble,  the  pulse  rapid  and  flickering. 

A  child  in  this  condition  m.ust  be  watched  most  closely,  as  dyspnea, 
cyanosis,  coldness  of  the  extremities,  pallor,  and  restlessness  may 
become  urgent  at  any  moment,  and  require  the  m.ost  prompt  treatment. 
Usually  there  is  no  edema,  and  pain  in  the  chest  and  precordial  distress 
are  comparatively  rare.  Diminished  blood-pressure,  weakness  of  the 
cardiac  impulse  and  heart  sounds  (the  second  sound  may  almost  entirely 
disappear  and  the  pulse  at  the  wrist  be  lost)  are  danger  signals  of 
impending  cardiac  dilatation. 

In  fulminant  cases  diphtheritic  myocarditis,  purely  toxic  in  origin, 
may  cause  sudden  death  during  the  first  few  days,  or  in  the  second  or 
third  week,  or  during  convalescence,  and  as  late  as  the  sixth  to  the 
eighth  week.  Pallor,  cold  extremities,  cyanosis,  vomiting,  and  syncope 
are  ominous  signs.  In  mild  cases  an  irregular  pulse  on  even  slight 
exertion  m,ay  persist  for  months  after  recovery. 

The  rapid  pulse  of  the  first  week,  and  bradycardia  during  the  second 
week  of  scarlet  fever,  are  in  all  probability  also  due  to  myocarditis. 
Typhoid  fever  is  much  less  apt  to  affect  the  cardiac  m.uscle  in  children 
than  in  adults,  manifesting  itself  chiefly  by  arrhythmia,  and  rarely 
leads  to  heart  failure. 

Chronic  myocarditis  sometimes  follows  the  acute  form  of  myo- 
carditis, but  develops  more  frequently  after  diphtheria.  There  may  be 
tachycardia,  more  rarely  bradycardia,  often  arrhythmia,  and,  upon 
slight  exertion,  dilatation  of  the  heart.  The  most  important  symptom  is 
increasing  muscular  insufficiency,  just  as  in  the  later  stages  of  chronic 
valvular  disease.  • 

Diagnosis. — This  is  doubtful,  especially  during  the  febrile  period  of 
infectious  diseases,  in  which  case  the  abnormal  pulse  is  often  due  to 
vasomotor  disturbance  or  an  affection  of  the  nervous  system.  Increased 
cardiac  dulness  with  acute  nephritis,  which  follows  scarlet  fever,  for 
example,  might  be  mistaken  for  that  of  myocarditis  if  it  were  not  for 
the  hardened  pulse.  Diagnosis  is  mainly  based  upon  an  irregular  and 
weak  pulse  following  infectious  disease,  upon  sudden  attacks  of  cyanosis 
and  collapse,  and  upon  a  weak  and  impure  first  sound  while  the 
second  may  be  ahnost  lost. 

Prognosis. — This  is  always  doubtful;  an  advanced  case  seldom 
permanently  improves.  Early  and  sudden  death  is  almost  invariably 
to  be  expected,  especially  in  diphtheria,  unless  the  most  careful  treat- 
ment can  be  instituted  early;  this  should  be  continued  for  m.onths  or 
for  years. 

Treatment. — The  treatment  of  chronic  myocarditis  is  purely  symp- 
tomatic, and  is  directed  to  lightening  the  work  of  the  heart  and  over- 
coming the  disturbed  circulation.  When  it  follows  even  a  mild  attack 
of  an  infectious  disease,  absolute  rest  in  bed  is  necessary.  The  child 
should  not  be  allowed  to  lift  its  head  from  the  pillow,  a  trained  nurse 
should  be  constantly  on  the  watch  to  prevent  any  physical  exertion  or 


MYOCARDITIS  471 

mental  excitement.  Needless  to  say,  that  even  the  child's  struggles 
against  certain  forms  of  treatment  may  be  detrimental. 

A  warm  sponge  bath  should  be  given  daily,  and  a  daily  movement 
of  the  bowels  without  straining  be  secured.  No  alcohol  or  coal-tar 
derivatives  are  allowable,  for  fear  of  further  damaging  the  already 
hampered  heart.  In  older  children  an  ice-bag  applied  over  the  heart, 
if  not  objected  to,  may  give  relief.  Easily  digested  food  should  be 
given  in  sm.all  quantities  at  frequent  intervals,  so  that  there  will  be  no 
distention  of  the  stomach  by  either  food  or  gas;  a  liquid  or  semi- 
liquid  diet,  containing  not  too  much  fluid,  answers  best. 

For  the  cardiac  weakness  digitalis  is  usually  of  little  use.  When 
the  pulse  becomes  weak,  and  dyspnea  and  cyanosis  appear,  camphor- 
ated oil  m.ay  be  given  subcutaneously  in  doses  of  ten  to  twenty  minims. 
Caffein  sodium  salicylate  or  caffein  sodium  benzoate  may  be  adminis- 
tered hypodermically  in  1-grain  doses,  three  times  a  day,  to  a  child 
three  to  five  years  old;  strychnine,  2-io"  of  a  grain  for  a  child  one  year 
old,  and  double  this  dose  at  three  years,  can  be  repeated  three  or  four 
times  daily,  and  may  be  pushed  even  to  its  physiological  effect — slight 
twitching  of  the  muscles  of  the  face  and  extremities ;  adrenaline — 30  to 
40  minims  of  a  roVo'  solution  in  normal  saline — m.ay  be  given  three  to 
six  tim.es  daily  subcutaneously.  It  is  probably  best  to  give  a  com- 
bination of  several  of  these  drugs,  although  in  som.ewhat  sm.aller  doses. 

How  long  should  a  convalescing  child  be  kept  under  strict  observa- 
tion? It  should  stay  in  bed  as  long  as  the  pulse  is  irregular,  or  more 
rapid  than  normal.  When  the  heart  seems  to  be  regular,  the  head  may 
be  raised  by  the  addition  of  an  extra  pillow,  subsequently  the  shoulders 
and  head  m.ay  be  elevated  until,  guided  by  the  cardiac  action,  the 
child  may  be  allowed  to  sit  up,  then  to  stand  up,  and  finally  to  walk. 


CHAPTER  XVI. 
DISEASES  OF  THE  BLOOD. 

THE    BLOOD   IN   INFANCY    AND    CHILDHOOD. 

The  blood  of  an  infant  or  child  shares  the  instability  of  the  pulse, 
temperature,  and  respiration  which  is  characteristic  of  childhood. 
Just  as  some  slight  disturbance  will  give  a  hyperpyrexia  with  very 
rapid  pulse  in  a  child,  so  are  grave  anemias  and  high  leucocyte  counts 
resultant  from  causes  which  would  scarcely  alter  the* blood  of  an 
adult.  This  exaggerated  response,  which  occurs  whether  the  cause  be 
pathological  or  physiological,  is  due  to  the  as  yet  incomplete  establilt^- 
ment  of  the  function  of  producing  blood,  further  shown  by  th^slow 
regeneration  of  the  cellular  elements  after  hemorifeges  and  the 
prompt  appearance  of  abnormal  red  and  M^hite  cells  whenever  the 
blood-forming  organs  are  taxed.  The  fact  that  cej-lt^in  toxins 
acting  on  the  child's  blood  for  the  first  time,  must  also  be  taken  into 
consideration.  With  this  knowledge  in  mind,  we  consider  the  blood 
findings  in  early  childhood  far  less  significant  than  in  adult  life. 

Physical  Properties. — Color. — The  infant's  blood  is  darker  for  the 
first  few  days,  but  quickly  assumes  the  normal  color. 

Reaction. — The  reaction  is  always  alkaline. 

Specific  Gravity. — Specific  gravity  is  about  1.065  at  birth  and 
fluctuates  till  the  end  of  the  first  year  when  it  reaches  the  normal  level 
of  about  1.055.  The  specific  gravity  is  uninfluenced  by  the  number  of 
cells  or  other  causes,  such  as  food,  rest  or  exercise,  but  is  in  direct 
proportion  to  the  amount  of  hemoglobin. 

Hemoglobin. — There  is  a  greater  amount  of  hemoglobin  at  birth 
than  in  adult  life  due  to  a  higher  percentage  in  the  individual  red  cell, 
the  amount  ranging  from  104  to  110  per  cent,  of  that  found  in  adult  life. 
This  higher  percentage  sinks  quickly  after  birth  and  at  six  weeks  55 
to  65  per  cent,  is  normal  with  proportionate  color  index.  From  the 
sixth  month  to  the  second  year,  it  is  lower  than  in  adult  life,  and,  in 
the  normal  child  during  this  time,  it  may  go  as  low  as  60  per  cent,  and 
is  rarely  above  80  per  cent.;  then  there  is  a  steady  rise  till,  at  six 
years,  it  reaches  normal  adult  percentage.  As  a  general  rule,  the 
percentage  of  hemoglobin  is  higher  in  boys  than  in  girls.  In  all  the 
various  forms  of  anemia,  the  amount  of  hemoglobin  is  reduced. 

Red  Cells. — The  number  of  erythrocytes  is  increased  at  birth  and 
counts  run  as  high  as  8,000,000.  They  remain  high  for  about  twenty- 
four  hours,  but  begin  to  diminish  the  second  day.  Throughout 
childhood  the  number  of  oscillations  in  twenty-four  hours  is  greater 
than  in  the  adult.  A  few  nucleated  red  cells  may  be  seen  at  birth, 
but  these  disappear  in  the  course  of  a  few  days;  they  are  rarely  found 


THE  BLOOD  IN  INFANCY  AND  CHILDHOOD  473 

in  the  blood  of  normal  children  but  are  common  in  premature  infants. 
Erythrocytes  vary  greatly  in  size,  shape,  and  staining  reaction;  they 
are  particularly  susceptible  to  structural  damage  from  trivial  causes. 

Normoblasts  are  normal-sized  erythrocytes  with  a  dark  staining 
nucleus.  They  are  found  in  both  mild  and  severe  anemias,  in  disease 
of  the  bone  marrow  and  in  severe  leukocytosis. 

*Megaloblasts  are  very  large  red  cells,  10  to  20  micromillimeters  (fx) 
in  diameter,  with  nuclei  of  various  shapes  and  polychromatic.  They 
occur  in  very  young  infants  and  in  pernicious  anemia,  and  indicate 
blood  regeneration. 

Microcytes  are  small  red  cells  from  4  to  10  fx  in  diameter.  They 
are  seen  in  chlorosis  and  severe  anemias. 

Poikilocytes  are  irregular  shaped  cells  occurring  in  severe  anemias. 

The  number  of  red  blood  cells  is  diminished  in  both  primary  and 
secondary  anemias.  The  red  cells  are  increased  during  cyanosis,  at 
the  sea  coast  and  in  high  altitudes. 

Leukocytes. — There  is  a  physiological  leukocytosis  at  birth  averaging 
20,000  to  30,000,  followed  by  a  rapid  reduction  to  about  12,000  during 
the  next  ten  days.  At  the  end  of  the  first  year,  they  average  9000  in 
number,  and  vary  between  6000  and  12,000  during  childhood. 

Normal  Varieties.- — The  following  types  are  seen  normally  in  the 
child's  blood: 

Small  Mononuclears. — These  comprise  40  to  60  per  cent,  of  the 
leukocytes  in  the  blood  of  children.  They  are  the  size  of  a  red  corpuscle 
and  have  a  large  deeply  staining  nucleus. 

Large  Mononuclears. — ^This  variety  is  two  or  three  times  larger  than 
the  small  lymphocyte  and  has  an  oval  nucleus  not  exactly  centrally 
placed,  which  stains  faintly.  It  comprises  from  4  to  18  per  cent,  of 
leukocytes  in  children. 

Polynuclears. — These  cells  are  smaller  than  the  large  lymphocytes, 
and  the  nuclei  stain  deeply  with  basic  dyes.  The  nucleus  has  the 
appearance  of  being  composed  of  several  parts  joined  together.  The 
protoplasm  of  the  cell  contains  small  granules  which  stain  with  neutral 
dyes.  While  these  cells  make  up  60  to  70  per  cent,  of  the  total  number 
of  leukocytes  in  the  adult,  in  childhood  they  average  from  20  to  40 
per  cent,  of  the  white  cells. 

EsinopJiiles. — These  resemble  polynuclears  but  the  granules  are 
larger  and  stain  deeply  with  acid  dyes.  They  average  2  to  4  per  cent, 
of  the  leukocytes  in  childhood. 

Mast  Cells. — This  name  is  given  to  leukocytic  cells  whose  granules 
stain  only  with  basic  dyes,  not  at  all  with  triacid.  They  may  be 
either  mononuclear  or  polynuclear,  and  are  never  seen  in  early  child- 
hood. They  are  differentiated  from  the  finely  granular  basophiles 
as  follows:  The  mast  cell  has  a  pale  nucleus  which  is  usually  single 
and  may  be  indented  and  takes  basic  stain  very  faintly,  while  finely 
granular  basophiles  are  darker  and  lobed  or  polynuclear,  the  nuclei 
taking  a  moderate  amount  of  basic  stain.  The  finely  granular  baso- 
phile  is  the  size  of  a  polyneutrophile,  while  the  mast  cell  is  much  larger. 


474  DISEASES  OF  THE  BLOOD 

Pathologic  Forms. — ^Myelocytes  have  a  single  rounded  nucleus  and 
contain  neutrophilic  granules.  There  is  also  a  non-granular  type 
observed  in  severe  anemias. 

Mononuclear  eosihophiles  appear  in  the  pathological  blood.  They 
resemble  polynuclear  eosinophiles  and  are  called  eosinophilic  myelocytes. 

Leukocytosis. — In  adults,  leukocytosis  is  practically  always  caused 
by  an  increase  in  the  polynuclear  cells,  but  in  childhood  there  is  a 
greater  tendency  for  the  lymphoc\i;es  to  increase,  as  is  seen  in  per- 
tussis, hereditary  syphilis,  scurvy,  and  rachitis. 

A  polynuclear  increase  in  children  indicates  the  presence  of  actual 
pus  formation,  septicemia,  or  severe  intoxication.  It  also  occurs  in 
pneumonia  and  diphtheria.  A  physiological  increase  follows  cold 
bathing,  eating,  exercise,  and  massage.  An  eosinophilia  is  noted  in 
certain  cases  of  chronic  skin  diseases  and  is  also  seen  when  there  is 
infestation  by  intestinal  parasites. 

Leukocytes  may  be  practically  unchanged  as  to  number  in  measles, 
mumps,  German  measles,  and  most  forms  of  tuberculosis  in  children. 
Actual  lymphocytosis  in  acute  infections  of  childhood  sometimes 
resembles  the  blood  picture  of  acute  lymphatic  leukemia. 

A  leukopenia  is  a  diminution  in  the  number  of  leukocytes  and  is 
frequently  observed  in  cases  of  malnutrition,  the  latter  weeks  of 
typhoid  fever,  certain  forms  of  pure  tubercular  infection,  and  various 
anemias. 

.  A  normal  leukoc^le  count,  or  a  leukopenia  in  a  disease  which  usuallj' 
produces  a  leukocytosis,  indicates  an  overwhelming  infection  with  no 
reaction  on  the  part  of  the  patient,  and  justifies  an  unfavorable 
prognosis. 

The  diagnostic  value  of  leukocytosis,  in  a  few  of  the  commoner 
diseases,  of  children,  is  emphasized  below: 

Diyhtheria. — There  is  a  marked  leukocytosis  in  most  cases,  and, 
although  there  is  no  direct  ratio  between  the  degree  of  leukocytosis 
and  the  clinical  findings,  the  most  severe  cases  are  accompanied  by  the 
highest  leukocyte  counts.  The  presence  of  myelocytes  is  regarded 
by  some  observers  as  a  fatal  prognostic  sign. 

Empyema. — ^A  rise  in  the  leukocyte  count  during  the  course  of,  or 
following  a  pneumonia,  with  no  changes  in  the  lungs  to  warrant  it, 
is  strongly  suggestive  of  a  beginning  empyema. 

Meningitis. — Septic  meningitis  is  always  accompanied  by  a  leuko- 
cytosis. Cerebrospinal  meningitis  causes  a  leukocytosis  in  most  cases, 
but  in  the  tubercular  form  it  is  by  no  means  constant,  and,  if  present, 
only  to  a  slight  degree. 

Pertussis. — From  the  very  onset  of  this  disease,  there  is  usually  a 
high  leukocytosis,  especially  under  five  years. 

Pneumonia. — There  is  a  marked  leukocytosis  in  pneumonia  which 
increases  from  the  onset  of  the  disease  to  the  crisis,  when  it  falls 
rapidly.  The  usual  count  is  from  20,000  to  30,000,  although  it  fre- 
quently reaches  50,000  and  may  go  above  100,000.  A  low  leukocyte 
count  is  against  a  pneumonia,  but  when  it  occurs  it  is  an  ominous  sign. 


ANEMIA  475 

Tuberculosis. — There  is  no  increase  in  the  number  of  leukocytes 
unless  a  mixed  infection  exists. 

Scarlet  Fever. — ^A  leukocytosis  is  present  which  reaches  its  maximum 
on  the  second  or  third  day  of  the  disease,  and  is  of  value  in 
differentiating  this  disease  from  measles. 

Blood  Platelets. — These  are  small  colorless  cells,  usually  found  in 
clumps,  and  have  no  known  significance,  except  that  thrombi  are  more 
apt  to  form  when  they  are  increased. 

Blood  Dust. — ^This  is  the  title  given  to  the  colorless  granules  ranging 
up  to  1  ju  in  diameter,  found  in  normal  blood.  They  are  highly 
refractile  and  possess  a  dancing  motion,  but  their  function  has  not 
been  discovered. 

.  ANEMIA. 

In  childhood,  as  in  adult  life,  we  have  two  forms  of  anemia,  the 
primary  and  secondary. 

Secondary  anemias  are  more  common  and  much  more  easily  pro- 
duced in  children,  frequently  reachmg  an  alarming  degree.  Primary 
anemias  are  rare,  and  the  distinct  types  are  less  clearly  defined. 

Secondary  or  Simple  Anemia. — Secondary  a-nemia  is  that  condition 
of  the  blood  in  which  the  changes  found  are  the  result  of  disease,  poor 
hygiene,  or  other  causes  acjting  on  the  general  system  and  causing  an 
impoverishment  of  the  blood,  the  blood-forming  organs  being  involved. 

Etiology. — Hemorrhage  is  very  apt  to  produce  a  well-marked 
anemia  in  children,  if  at  all  severe  or  prolonged.  Malnutrition  is  the 
common  cause  of  anemia  in  infancy.  Anemia  follows  many  of  the 
acute  infections,  the  severity  depending  on  the  previous  condition  of 
the  child  and  the  intensity  of  the  disease.  Syphilis,  tuberculosis, 
rachitis,  malaria,  and  scurvy  all  produce  a  secondary  anemia.  Poor 
food,  lack  of  fresh  air,  prolonged  grief  or  worry  and  severe  mental 
strain  are  other  important  factors.  The  poor  physical  condition  of  a 
mother  during  gestation  may  be  responsible  for  an  anemic  child.  The 
administration  of  certain  drugs  and  the  action  of  certain  toxins  gener- 
ated within  the  body  cause  anemia.  Children  with  chronic  heart 
disease  or  nephritis  are  usually  anemic. 

Symptoms. — Pallor  of  the  skin  and  mucous  membranes  and  pearly 
white  conjunctiva  are  the  common  visible  signs.  The  child  may  or 
may  not  be  emaciated,  but  is  listless,  languid,  fatigues  easily,  has  a 
poor  and  capricious  appetite,  and  is  apt  to  be  irritable  and  restless. 
Headache,  fainting  spells  and  hemorrhages  from  the  nose  or  other 
mucous  membranes  are  frequent.  Enuresis  is  common  and  edema 
may  be  present  in  the  dependent  tissues  with  no  albuminuria.  This  is 
due  to  the  poor  circulation,  which  also  causes  the  child  always  to  feel 
cold,  and  to  become  cyanotic  and  dyspneic  on  exertion.  The  heart 
sounds  are  weak  and,  after  the  third  year,  hemic  mm-mm-s  are  usually 
present.  Fever  is  not  constant,  but  the  child  is  subject  to  repeated 
and  prolonged  chills.  The  spleen  is  usually  enlarged — the  liver  may 
be. 


476  DISEASES  OF   THE  BLOOD 

Blood  Picture.^ — The  blood  changes  are  much  more  marked  m  the 
secondary  anemia  of  children  than  in  adult  life.  If  the  anemia  be 
a  mild  one,  there  may  simply  be  a  reduction  of  the  hemoglobin  and 
red  cells,  generally  with  a  leukocytosis.  The  blood  of  the  infant  or 
very  young  child  easily  reverts  to  the  embryonal  type  and.  the  presence 
of  microcytes,  megalocytes,  normoblasts,  and  megaloblasts,  is  noted. 
Poikilocytosis  and  polychromatophilia  are  frequent.  The  hemoglobin 
may  fall  to  20  per  cent,  or  even  below,  and  the  red  cells  be  less  than 
1,000,000  in  severe  cases.  The  average  anemic  child  has  a  hemoglobin 
content  of  from  40  per  cent,  to  50  per  cent.,  with  the  red  cells  about 
half  their  normal  number. 

Diagnosis. — The  diagnosis  is  quite  simple  if  the  etiological  factor  is 
apparent,  but  in  the  absence  of  a  known  cause  it  is  difficult.  The 
blood  picture  may  reveal  many  of  the  embryonal  types  of  cells  with 
an  indifferent  cell  count,  and  render  the  differentiation  between  a 
severe  secondary  anemia  and  one  of  the  primary  anemias  impossible. 
Under  treatment,  however,  the  secondary  anemia  usually  improves, 
while  the  primary  anemia  progresses  in  spite  of  all  remedial  measures. 

Prognosis. — The  prognosis  depends  on  the  severity  of  the  anemia 
and  the  cause.  Leukocytosis  is  regarded  as  a  bad  sign.  The  presence 
of  pathological  red  cells,  a  high  color  index,  and  very  low  hemoglobin 
content  or  red  cell  count  indicate  a  severe  grade  of  anemia  in  which  the 
outcome  is  apt  to  be  unfavorable. 

Treatment. — Unless  the  case  be  very  severe,  the  removal  of  the  cause 
soon  results  in  a  marked  improvement  and  return  to  normal.  Fresh 
air,  good  hygiene  and  nourishing  food  are  absolutely  necessary.  Iron 
is  perhaps  the  one  best  drug,  and  is  given  to  young  children  and  in- 
fants, preferably,  in  the  form  of  the  saccharated  carbonate,  albuminate 
or  peptomanganate.  Iron  citrate  is  far  more  effective  when  given 
intramuscularly  than  when  given  by  mouth.  One  to  2  grains  may  be 
given  daily  and  will  cause  a  rapid  and  lasting  increase  in  the  hemo- 
globin and  number  of  erythrocytes.  No  untoward  effects  occur  if 
the  injection  is  given  carefully  and  all  forms  of  anemia  respond  very 
well  to  this  treatment.  Older  children  may  be  safely  given  the  same 
preparations  as  adults.  Arsenic,  in  the  form  of  Fowler's  solution, 
may  be  given  advantageously,  where  iron  is  not  tolerated,  or  in 
conjunction  with  the  iron. 

The  Primary  Anemias. — By  the  term  primary  anemia,  we  mean  those 
conditions  of  the  blood  due  to  changes  in  the  blood-forming  and  blood- 
destroying  organs  and  tissues  of  the  body.  Primary  anemias  are  very 
rare  during  childhood. 

Chlorosis. — Chlorosis  is  a  primary  anemia  of  gradual  onset  and 
runs  a  chronic  course  in  which  relapses  are  common.  It  is  char- 
acterized by  a  reduction  of  hemoglobin  wholly  disproportionate  to  the 
diminution  of  the  red  cell  count. 

Etiology. — This  is  a  disease  of  late  childhood,  occurring  about 
puberty.  Although  a  few  cases  have  been  reported  before  the  fifth 
year,  these  are  probably  cases  of  chlorotic  blood  and  not  true  chlorosis. 


ANEMIA  477 

It  is  usually  seen  in  girls,  particularly  of  the  blonde  type;  rarely  in 
boys.  Heredity  is  regarded  as  a  possible  factor.  The  exciting  cause 
is  unknown,  but  overwork,  close  confinement,  undernourishment,  and 
poor  hygienic  conditions  predispose  to  it.  Psychical  elements,  as 
shock,  grief,  care,  fright  and  excessive  mental  strain  should  not  be 
overlooked.  Clark's  view,  that  auto-intoxication  is  largely  responsible, 
is  supported  by  the  frequent  history  of  constipation  elicited  in  these 
cases. 

Pathology. — Postmortem  findings  have  shown  a  hypoplasia  of  the 
heart  and  large  vessels,  and  occasionally  of  the  uterus  and  ovaries. 
There  is  usually  a  fatty  degeneration  of  the  heart  muscle,  and  the  right 
heart  may  be  dilated  with  hypertrophy  of  the  left  ventricle.  Death, 
if  it  occurs,  is  generally  due  to  a  complicating  tuberculosis  or  round 
ulcer  of  the  stomach. 

Symptoms. — The  symptoms  are  those  of  a  simple  anemia.  Dyspnea, 
palpitation,  attacks  of  vertigo,  and  syncope  are  common.  The  appe- 
tite is  poor  and  frequently  perverted.  Constipation  is  the  rule. 
The  menstrual  periods  may  be  very  painful  and  amenorrhea  is  gen- 
erally present,  probably  as  a  result  rather  than  a  cause  of  the  disease. 
Enteroptosis  and  hyperacidity  are  often  found.  The  heart  may  show 
evidence  of  right-sided  dilatation  and  hypertrophy  of  the  left  ventricle. 
A  hemic  murmur,  systolic  in  time,  is  heard  over  the  mitral  and  pul- 
monic areas.  There  is  a  venous  hum  in  the  neck  with  palpitation  in 
the  jugular  veins.  Thrombosis  is  more  apt  to  occur  in  the  femorals. 
The  pulse  is  soft  and  weak.  Headache,  neuralgia,  hysteria  and 
chorea  are  among  the  nervous  manifestations.  There  may  be  edema 
of  the  feet,  puffiness  of  the  face,  and  occasionally  albuminuria.  This 
disease  is  also  called  "green  sickness"  because  of  the  yellowish-green 
tinge  of  the  skin.  Pigmentation  is  occasionally  noted.  There  is 
apparently  no  emaciation  and  the  patient  may  look  plump  and  healthy. 

Blood  Picture. — The  gross  changes  in  the  blood  are  the  pale  color, 
rapid  coagulability,  and  low  specific  gravity.  Under  the  microscope, 
the  blood  shows  a  moderate  decrease  in  the  number  of  red  cells,  the 
count  ranging  from  4,000,000  down  to  1,000,000 — rarely  below. 
Nucleated  red  cells  are  common,  normoblasts  predominating;  megalo- 
blasts  never  occur.  Each  individual  red  cell  is  pale,  smaller,  and  one 
is  occasionally  deformed.  There  is  no  leukocytosis,  but  a  lymphocyto- 
sis with  absolute  diminution  of  polynuclears.  The  hemoglobin  is 
greatly  reduced,  frequently  as  low  as  35  per  cent,  to  40  per  cent.  The 
color  index  is  low.  The  blood  platelets  are  markedly  increased, 
perhaps  accounting  for  the  shortened  coagulation  time. 

Diagnosis. — The  color  of  the  skin  and  the  blood  picture  are  char- 
acteristic. Age,  sex,  and  the  functional  derangement  of  the  heart  are 
of  additional  help. 

Prognosis. — The  prognosis  in  uncomplicated  cases  is  uniformly 
good;  death,  if  it  occurs,  is  usually  due  to  a  complicating  tuberculosis 
or  gastric  ulcer.  The  average  case  lasts  a  year;  exceptionally,  cases 
will  go  on  for  several  years. 


478  DISEASES  OF   THE  BLOOD 

Pernicious  Anemia. — This  is  the  most  severe  form  of  anemia  known. 
It  pursues  a  progressive  course,  accompanied  by  constant  blood 
changes,  and  rapidly  goes  on  to  a  fatal  termination. 

Etiology. — It  is  not  a  common  disease  in  early  life,  and  the  greatest 
number  of  the  cases  in  children  occur  in  later  child  life.  No  specific 
cause  has  been  discovered,  and  the  nature  of  this  disease  is  as  yet 
unknown.  Syphilis,  rachitis,  and  infestation  by  intestinal  parasites 
have  been  observed  in  some  cases.  Others  have  followed  a  severe 
simple  anemia  or  a  grave  nutritional  disturbance.  There  is  unquestion- 
ably a  red  cell  destruction  and  that  this  is  a  toxic  hemolysis  is  very 
probable.  It  is  believed  that  these  toxins  are  absorbed  from  the  intes- 
tinal tract,  and  the  peculiar  deposits  of  iron  in  the  hepatic  cells  have 
led  to  the  theory  that  most  of  this  red  cell  destruction  occurs  in  the 
liver. 

Pathology. — There  is  a  severe  anemia  of  all  the  viscera.  Fatty 
degeneration  is  particularly  marked  in  the  heart,  bloodvessels,  liver, 
and  kidneys.  Capillary  hemorrhages  of  the  viscera  and  skin  are 
common.  The  heart  is  larger  than  normal,  and  very  flabby.  The 
liver  is  enlarged,  and  histological  findings  of  iron  pigments  in  the  liver 
cells  are  characteristic.  This  deposit  of  iron  is  sometimes  noted  in  the 
intestinal  mucosa.  The  mucous  lining  of  the  stomach  is  apt  to  atrophy. 
The  spleen  is  enlarged,  as  it  is  commonly  found  to  be  in  all  blood 
diseases  of  children.  The  bone-marrow  is  darker  and  softer  and  simu- 
lates the  embryonic  state,  the  changes  being  due  to  reversion  to  an 
embryonal  type  and  similar  type  of  hemogenesis.  It  contains  numer- 
ous nucleated  red  cells.  The  lymph  nodes  are  enlarged  and  congested. 
Loss  of  flesh  is  not  constant. 

Symptoms. — ^The  patient,  while  not  emaciated,  is  very  weak  and 
frequently  prostrated.  The  skin  and  mucous  membranes  are  pale. 
The  onset  is  very  gradual  and  may  be  accompanied  by  no  symptoms 
until  the  disease  has  progressed  fairly  well.  There  are  disturbances 
of  digestion,  causing  nausea  and  vomiting.  The  heart  may  be  dilated, 
hemic  murmurs  are  common,  and  the  pulse  is  soft  and  full.  Dyspnea 
follows  exertion  and  there  is  restlessness  and  insomnia.  Fever  is 
generally  present,  but  it  is  irregular.  The  urine  is  scanty  with  low 
specific  gravity  and  contains  no  albumin.  Dropsy  may  appear  in 
the  dependent  tissues,  and  exceptionally  in  the  serous  cavities.  Late 
symptoms  include  epistaxis  and  hemorrhages  from  other  mucous 
membranes  and  ecchymoses  of  the  skin.  The  duration  of  the  disease 
is  shorter  in  children  than  in  adults,  usually  terminating  in  less  than  a 
year. 

Blood  Picture. — The  drop  is  very  pale,  its  fluidity  is  increased,  and 
the  coagulation  time  delayed.  The  specific  gravity  is  low.  The 
hemoglobin  usually  falls  below  30  per  cent.,  and  at  the  time  objective 
symptoms  appear,  the  red  cell  count  is  1,000,000  or  less.  During 
remissions,  the  number  of  red  cells  may  tend  to  approach  normal,  but 
rapidly  decreases  again  in  the  relapses,  so  that  in  the  later  stages  a 
count  below  500,000  is  not  uncommon.     Abnormal  red  cells  are  abun- 


LEUKEMIA  479 

dant  and  the  megaloblasts  exceed  the  normoblasts  in  number.  Micro- 
blasts  are  rarely  met  with.  Karyokinesis  is  common,  and  the  non- 
nucleated  red  cells  are  deformed,  variable  in  size,  and  show  poly- 
chromatophilia.  Diffuse  basophilia,  punctate  basic  degeneration,  and 
basic  nuclear  remains  are  very  common.  Rouleaux  formation  is  absent. 
The  white  blood  cells  are  diminished  as  a  whole,  but  in  infants  they 
may  be  increased.  Lymphocytosis,  which  occurs  in  the  severe  cases, 
is  accompanied  by  a  diminution  in  the  number  of  polynuclears. 
Myelocytes,  if  present  at  all,  are  very  few  in  number,  and  eosinophilia 
is  observed  where  there  is. infestation  by  intestinal  parasites. 

Diagnosis. — This  is  based  almost  entirely  on  the  blood  picture,  of 
which  the  following  are  the  distinguishing  features :  An  extremely  low 
red  cell  count,  high  color  index,  marked  poikilocytosis,  the  predomi- 
nance of  megaloblasts,  and  lymphocytosis  with  diminution  of  poly- 
nuclears. In  early  infancy,  a  severe  secondary  anemia  will  so  closely 
simulate  a  pernicious  anemia  that  it  can  be  ruled  out  only  by  the 
absence  of  any  causative  factor. 

Prognosis. — The  great  majority  of  cases  end  fatally.  A  few  cases 
have  recovered  in  which  intestinal  parasites  or  rachitis  were  associated 
and  effectively  treated.  High  color  index,  few  normoblasts,  and  many 
megaloblasts  foretell  a  fatal  termination,  while  an  increasing  number 
of  normoblasts  indicates  efforts  at  regeneration  and  is  regarded 
favorably. 

LEUKEMIA. 

This  is  a  disease  in  which  there  is  a  steady  and  persistent  increase  in 
the  number  of  white  blood  cells.  The  red  cells  are  but  moderately 
reduced,  although  abnormal  forms  are  frec|uently  present.  There  are 
gross  changes  in  the  spleen,  lymph  glands,  and  bone  marrow.  Three 
forms  are  met  with  which  differ  as  to  the  blood  picture  and  pathological 
findings.  They  are  the  splenomyelogenous  type  and  the  lymphatic, 
which  may  be  acute  or  chronic. 

Etiology. — Children  are  sometimes  the  subject  of  this  disease,  but 
it  rarely  occurs  in  the  purely  myelogenous  form.  The  lymphatic 
variety  is  more  common,  and  congenital  cases  have  been  reported 
together  with  several  in  early  infancy.  Males  are  more  liable  to  suffer 
from  this  disease  than  females.  It  may  follow  the  acute  infections 
and  has  been  observed  m  cases  of  congenital  lues,  rachitis  and  malaria, 
but  the  relation  is  very  obscure.  Simple  anemia  has  been  followed 
by  leukemia  and  in  some  cases  it  occurs  primarily  in  a  healthy  child. 
Various  observers  have  believed  in  its  infectious  nature,  or  that  it  may 
be  a  disease  of  the  lymphatic  system,  or  a  later  sequence  of  any  anemia 
under  certain  conditions. 

Pathology. — ^The  spleen,  lymphatic  glands  and  bone  marrow  show 
distinct  changes.  In  the  lymphatic  form  there  is  a  general  glandular 
enlargement  with  slight  enlargement  of  the  spleen  and  liver,  and  little 
or  no  apparent  change  in  the  bone-marrow.  The  lymphoid  structures 
of  the  alimentary  tract  may  also  be  affected.     In  the  splenomyelog- 


480  DISEASES  OF   THE  BLOOD 

enous  type,  there  are  marked  changes  m  the  spleen  and  bone  marrow, 
and  enlargement  of  the  liver.  The  spleen  is  greatly  enlarged,  due  to  a 
chronic  hyperplasia,  and  may  occupy  half  of  the  abdominal  cavity. 
In  the  early  stages,  it  is  soft  and  pulpy,  and  becomes  firm  and  hard 
as  the  disease  progresses,  and  a  perisplenitis  usually  develops.  Lym- 
phoid masses  are  scattered  throughout  the  body  of  the  spleen,  and 
microscopic  lymphoid  deposits  are  found  in  close  proximity  to  the 
arteries.  There  is  a  great  increase  in  the  number  of  leukocytes  in  the 
spleen.  The  bone-marrow  contains  a  greater  number  of  red  and  white 
marrow  cells,  the  fat  content  being  reduced.  Myelocytes  and  various 
other  cells,  including  red  cells  in  all  stages  of  development,  replace 
the  fatty  portion  of  the  marrow.  The  enlarged  liver  is  diie  to  infiltra- 
tion and  formation  of  lymphomata,  which  cause  a  marked  increase  in 
size  in  either  form  of  leukemia.  Other  organs  are  occasionally  the 
site  of  lymphoid  infiltration. 

Symptoms. — The  onset  is  gradual,  but  the  progress  is  rapid  and  the 
course  is  apt  to  be  more  acute  in  childhood,  although  chronic  forms 
occur.  General  weakness  with  pallor,  dyspnea  and  digestive  disturb- 
ances are  first  noticed.  Sight,  hearing  and  the  nervous  system  are 
frequently  deranged.  Abdominal  enlargement  or  glandular  swellings 
may  precede  any  of  the  above  symptoms.  Hemorrhages  of  the 
mucous  membranes  occur  in  the  nose,  stomach  and  intestines,  and 
there  may  be  hemorrhage  from  the  kidney  or  into  the  skin.  The 
heart  shows  no  symptoms,  although  the  pulse  is  weak  and  rapid,  and 
attacks  of  vertigo  are  common.  There  is  tenderness  over  the  shafts 
of  the  long  bones.  Albuminuria  occasionally  occurs,  and  there  may 
be  a  varying  amount  of  fever. 

Blood  Picture. — The  blood  is  opaque  and  flows  sluggishly,  but  the 
coagulation  time  is  normal,  or  but  slightly  increased.  The  hemoglobin 
is  usually  much  reduced.  The  average  red  cell  count  is  about  3,000,000. 
Nucleated  red  cells  are  abundant  in  the  myelogenous  variety,  but 
rare  in  the  lymphatic.  As  the  disease  progresses,  the  red  cells  diminish, 
and  occasionally  fall  below  2,000,000.  The  leukocyte  count  varies  in 
the  two  forms,  being  about  50  per  cent,  greater  in  the  myelogenous 
type  where  the  average  count  is  400,000.  Each  variety  has  a  distinct 
blood  pictm-e,  which  enables  us  to  distinguish  the  three  forms.  Char- 
acteristic of  the  myelogenous  type  is  the  high  number  of  myelocytes, 
ranging  from  30  to  60  per  cent,  of  the  white  cells.  All  the  intermediate 
forms  of  leukocytes  between  the  ordinary  varieties  are  present.  The 
lymphatic  type,  if  chronic,  shows  a  lymphocytosis  made  up  of  about 
90  per  cent,  small  lymphocytes  with  few  myelocytes  or  eosinophiles. 
Acute  lymphatic  leukemia  is  characterized  by  an  increase  in  the  large 
lymphocytes  with  polynuclears  and  eosinophiles  in  very  small  numbers. 
The  other  forms  of  leukocytes  are  all  increased  absolutely,  but  relatively 
decreased.  The  proportions  of  white  cells  to  reds  may  run  from  1  to 
15  up  to  1  to  3  in  the  very  severe  cases.  Mixed  forms  of  leukemia  are 
met  with  in  children  which  are  neither  myeloid  nor  lymphatic,  but 
intermediate  between  leukemia  and  splenic  anemia  of  infants. 


LEUKEMIA  481 

Diagnosis. — The  diagnosis  is  based  solely  on  the  blood  picture. 
The  high  leukocyte  count  rules  out  Hodgkin's  disease.  The  presence 
of  pathological  forms  of  leukocytes  and  red  cells  differentiates  it  from 
an  ordinary  leukocytosis. 

Prognosis. — ^The  disease  runs  a  chronic  course.  There  may  be  remis- 
sions of  symptoms,  but  the  termination  is  practically  always  fatal. 

Pseudoleukemia  of  Infants  (von  Jaksch). — In  the  year  1889,  Von 
Jaksch  first  described  this  disease  which  is  a  severe  lymphatic  anemia 
occurring  only  in  infants.  It  is  characterized  by  a  leukocytosis  with 
a  decrease  in  red  cells  and  hemoglobin,  and  an  enormously  enlarged 
spleen. 

Etiology. — Practically  all  cases  occur  between  the  sixth  and 
eighteenth  months.  Most  of  the  cases  observed  have  been  associated 
with  rachitis,  and  a  few  with  syphilis.  Gastro-intestinal  disturbances 
have  preceded  this  disease.  It  has  been  suggested  that  it  may  develop 
from  a  severe  anemia. 

Pathology. — The  spleen  is  greatly  enlarged,  so  that  it  is  often 
apparent  to  the  eye  on  inspection  of  the  abdomen.  On  palpation,  we 
find  it  hard  and  firm  due  to  a  hyperplasia.  The  liver  is  somewhat 
enlarged,  and  is  firmer  than  normally.  The  lymph  nodes  show 
moderate  enlargement.  The  cellular  content  of  the  bone  marrow  is 
increased.  The  heart  and  lungs  are  negative,  the  kidneys  may  reveal  a 
degeneration  of  the  parenchyma. 

Syn).ptoms. — Emaciation  may  or  may  not  be  present,  although 
anorexia  and  other  gastro-intestinal  disturbances  are  common.  The 
skin  is  pale  and  waxy  and  occasionally  has  a  yellowish  tinge.  Denti- 
tion and  closure  of  the  fontanelles  may  be  delayed.  Jaundice  may 
be  present,  though  not  marked.  Very  often  the  parents  will  bring  a 
child  for  treatment  of  the  enlarged  spleen,  which  they  themselves  have 
noticed.  Enlargement  of  the  liver  and  lymph  nodes  is  generally  to 
such  a  degree  that  it  is  noted  in  clinical  examination. 

Blood  Picture. — The  specific  gravity  varies  between  1035  and  1045. 
The  hemoglobin  is  reduced  to  below  50  per  cent.,  as  a  rule,  and  may  go 
down  to  20  per  cent.  The  red  cell  count  commonly  falls  below 
2,000,000,  but  in  some  cases  it  is  3,000,000  and  above.  Various  types 
of  red  cells  are  present,  of  which  the  nucleated  reds  are  abundant. 
Megaloblasts,  microcytes  and  megalocytes  occur,  and  there  is  poikilo- 
cytosis  and  polychromatophilia.  Both  polynuclear  and  mononuclear 
leukocytes  are  increased  and  eosinophilia  may  occur.  There  are 
occasionally  a  few  myelocytes.  The  total  leukocyte  count  is  not  as 
high  as  in  true  leukemia,  and  varies  between  20,000  and  50,000.  In 
but  few  instances  do  these  cases  present  definite  blood  pictures,  and  the 
summary  above  merely  represents  the  characteristic  findings  in  the 
few  cases  so  far  observed.  Polymorphism  of  leukocytes  is  the  dis- 
tinctive change  and  a  high  white  cell  count  suggests  complicating 
factors. 

Diagnosis. — The  diagnosis  rests  chiefly  upon  the  blood  picture,  the 
enormous  size  of  the  spleen,  and  severe  gastro-intestinal  disturbances 
31 


482  DISEASES  OF  THE  BLOOD 

in  a  syphilitic  or  rachitic  infant.  The  lower  leukocyte  count  with 
paucity  of  myelocytes  and  the  ultimate  recovery  exclude  leukemia. 
Pernicious  anemia  has  a  high  color  index,  the  red  cells  are  fewer,  as  a 
rule,  and  myelocytes  do  not  occur  so  frequently  as  in  pseudoleukemia 
of  infants.  The  greatly  enlarged  spleen  and  presence  of  myelocytes 
in  the  blood  signify  more  than  a  mere  secondary  anemia. 

Prognosis. — Recovery  is  the  usual  outcome;  those  cases  which  are 
said  to  have  passed  on  to  a  true  leukemia  were  leukemia  from  the 
onset.  With  the  inception  of  an  intercurrent  disease,  the  prognosis 
should  be  guarded,  as  this  may  cause  a  fatal  termination. 

Treatment  of  Anemia  and  Leukemia. — The  general  management 
of  all  cases  of  anemia  is  the  same,  since  there  are  certain  measures 
which  are  beneficial  to  all  of  the  various  forms.  Fresh  air  in  abundance 
with  plenty  of  sunshine  is  of  distinct  importance.  Regulation  of  diet, 
proper  hygienic  surroundings,  and  a  change  of  scene  and  environ- 
ment are  of  great  value.  The  amount  of  exercise  is  governed  by  the 
severity  of  the  anemia  and  the  strength  of  the  patient.  If  the  anemia 
be  of  a  mild  grade,  moderate  exercise  should  be  advised,  but  care  must 
be  taken  to  avoid  fatigue.  The  severe  grades  of  anemia  require  rest 
in  bed,  but  this  should  not  exclude  fresh  air  and  sunshine.  The  food 
should  contain  a  maximum  of  nutrition,  but  must  be  given  in  small 
quantities  at  frequent  intervals,  since  the  gastro-intestinal  tract  is 
easily  disturbed.  Due  regard  to  this  susceptibility  should  be  given 
in  the  administration  of  drugs,  for,  with  digestion  and  assimilation 
below  par  or  deranged,  the  treatment  of  a  given  case  is  rendered  much 
more  difficult.  Cod-liver  oil,  beef  extracts,  phosphorus  and  strych- 
nine are  used  for  their  tonic  effect.  Iron  and  arsenic  each  has  a  distinct 
influence  in  the  treatment  of  anemia,  and  are  given  separately  or 
together.  Iron  in  the  form  of  the  citrate,  saccharated  carbonate, 
albuminate,  or  peptomanganate,  is  borne  best  by  infants,  and  very 
young  children;  the  chloride  is  recommended  for  later  childhood  life. 
Arsenic  is  indicated  at  times,  and  should  also  be  given  when  iron  is 
not  borne  well.  Iron  cacodylate  given  by  needle  is  the  best  form  of 
iron  in  all  severe  anemias,  dose  yV  to  I  grain.  Arsenic  may  be  given 
with  iron,  or  may  alternate  with  it.  Fowler's  solution  is  perhaps 
the  best  preparation  and  should  be  administered  in  ascending  doses 
to  the  point  of  tolerance.  In  all  cases  of  anemia,  although  it  is  very 
difficult  at  times,  an  earnest  endeavor  should  be  made  to  ascertain 
the  cause,  for,  if  this  be  found,  and  removed  before  the  anemia  has 
reached  a  fatal  degree,  prompt  recovery  will  usually  ensue. 

Secondary  Anemia.— If  this  is  due  to  hemorrhage,  it  must  be  met 
promptly  by  stimulation  of  the  patient,  warm  applications,  auto- 
transfusion  and  salt  solution  intravenously,  subcutaneously,  or  by 
rectal  irrigation.  When  due  to  disease  or  other  conditions,  the  cause 
should  be  removed  as  quickly  as  possible,  and  the  general  treatment, 
as  outlined,  should  be  carried  out. 

Chlorosis. — Iron  is  perhaps  the  best  drug  for  this  condition  and 
should  be  given  whenever  tolerated.     Arsenic  may  be  resorted  to  if 


SPLENIC  ANEMIA  483 

the  patient  cannot  take  iron,  or  may  be  used  with  iron.  The  general 
management  is  essentially  the  same  for  all  anemias. 

Pernicious  Anemia. — In  addition  to  the  general  management, 
other  measures,  such  as  continued  inhalations  of  oxygen  and  removal 
to  the  seashore  or  mountains,  should  be  resorted  to.  Arsenic  is  of 
more  value  in  this  disease  than  iron.  Glycerinized  extract  of  red  bone- 
marrow  has  been  given,  but  with  indifferent  results.  Stimulants  must 
frequently  be  resorted  to  because  of  the  extreme  exhaustion  and  weak- 
ness present.  Intestinal  parasites  should  be  looked  for  and  disposed 
of.  Recently  salvarsan  has  been  given  with  good  results,  and 
splenectomy  has  been  resorted  to  in  severe  cases. 

Leukemia. — The  treatment  of  leukemia  is  largely  symptomatic. 
The  general  management  should  be  carried  out.  Here  again  arsenic 
is  the  best  drug,  and  should  be  given  up  to  the  point  of  tolerance. 
X-ray  treatment  of  the  spleen  has  been  abandoned,  and  splenectomy 
in  this  disease  is  fatal.  Recently  the  use  of  the  .T-rays  upon  the 
epiphyses  of  the  long  bones  has  met  with  promising  results,  and  this 
procedure  should  be  tried.  German  investigators  report  good  results 
from  the  use  of  benzol  in  leukemia. 

Pseudoleukemia  of  Infants. — Strict  supervision  of  the  diet  and  careful 
attention  to  the  bowels  are  necessary.  The  underlying  cause  should 
be  ascertained  and  treated.  Iron  alone  or  iron  and  arsenic  alternating 
are  indicated.  Phosphorus  must  be  given  cautiously  and  is  of  doubtful 
value. 

SPLENIC   ANEMIA    (BANTI'S   DISEASE). 

This  is  a  severe  primary  anemia  accompanied  by  enlargement  of  the 
spleen  and  a  cirrhotic  condition  of  the  liver.  Both  red  and  white  cells 
are  diminished  in  number. 

Etiology. — Males  are  more  prone  to  this  disease  than  females  and 
the  majority  of  all  cases  occur  in  children  and  young  adults.  The 
exact  cause  has  not  been  discovered.  Syphilis  is  suspected  in  some 
cases.  There  exists  a  theory  that  the  greatly  enlarged  spleen  generates 
a  toxin  which  causes  the  disease.  Most  cases  occur  spontaneously  in 
otherwise  healthy  infants. 

Pathology. — The  spleen  may  attain  a  considerable  size.  The 
liver  is  smaller  and  cirrhotic.  Edema  may  be  present  in  the  dependent 
tissues  with  dropsical  fluid  in  the  serous  cavities.  Purpura  is  occasion- 
ally found. 

Symptoms. — Contrary  to  the  belief  of  Banti,  whose  name  this  disease 
bears,  we  find  the  first  symptoms  to  be  those  of  a  severe  anemia. 
Asthenia  is  marked  and  prostration  is  common.  Enlargement  of 
the  spleen  soon,  becomes  apparent,  and  the  organ  itself  is  apt  to  be 
painful.  The  heart  sounds  are  soft  and  weak  and  there  is  a  hemic 
murmur.  Edema  and  ascites  are  evident  as  the  disease  progresses, 
and  hemorrhage  may  occur  in  the  stomach,  intestines,  or  kidneys. 

Blood  Picture. — Hemoglobin  is  markedly  reduced  to  50  per  cent,  or 
below.     The  red  cell  count  rarely  falls  lower  than  3,000,000.     Poikilo- 


484 


DISEASES  OF  THE  BLOOD 


cj'tosis  and  the  presence  of  normoblasts  may  be  noted.  There  is  a 
lymphocytosis,  but  an  actual  leukopenia. 

Diagnosis. — The  enlarged  spleen  is  suggestive  of  leukemia,  but  this 
is  ruled  out  by  the  blood  findings,  which  show  a  leukopenia.  Splenic 
anemia,  because  of  its  rarity,  should  be  considered  only  after  careful 
study  of  the  case  excludes  a  chronic  suppuration,  syphilis,  or  tuberculosis. 

Prognosis. — The  prognosis,  in  cases  not  properly  treated,  is  grave, 
and  the  disease  runs  a  more  rapid  course  in  children  than  in  adults. 
The  treatment  is  radical,  and  for  this  reason  cjuite  a  few  cases  are  lost. 


Fig.  33. — Banti's  disease  in  a  child  aged  seven  years. 

Treatment. — Splenectomy  is,  at  present,  the  only  treatment  that 
gives  results.  This  is  often  a  dangerous  undertaking  owing  to  the 
severe  grade  of  anemia  which  is  present,  but  should  not  be  deferred, 
and  transfusion,  preferably  direct,  should  precede  the  operation. 


LYMPHATIC  ANEMIA  (PSEUDOLEUKEMIA:  HODGKIN'S  DISEASE). 

Primarily,  this  is  a  disease  of  the  lymph  structures,  but  it  is  discussed 
with  blood  diseases  to  distinguish  it  from  true  lymphatic  leukemia. 
It  is  characterized  by  persistent  enlargement  of  the  hmph  glands  and 
spleen,  and  the  formation  of  lymph  nodules  in  the  spleen,  liver,  and 
kidneys.     As  the  disease  progresses,  a  secondary  anemia  is  induced. 

Etiology. — It  is  a  disease  of  early  life,  although  few  cases  occur 
before  the  tenth  year.  It  is  more  common  in  boys  than  in  girls.  The 
exact  cause  is  unknown,  but  SA^hilis,  malaria  and  rachitis  are  regarded 


LYMPHATIC  ANEMIA  485 

as  predisposing  factors.  Tuberculous  involvement  of  the  affected 
structures  is  a  complication  rather  than  the  primary  cause.  No  acute 
infectious  agent,  which  gives  rise  to  Hodgkin's  disease,  has  been  found, 
although  this  probability  is  often  advanced.  The  patient  is  frequently 
in  apparent  good  health  at  the  onset  of  the  disease. 

Pathology. — There  is  hyperplasia  of  all  the  lymphatic  structures  of 
the  body.  Both  the  superficial  and  deep  lymphatic  glands  are 
enlarged,  and,  quite  commonly,  one  set  of  glands  in  particular  will  be 
greatly  hypertrophied.  This  occurs  most  often  in  the  neck.  In  the 
absence  of  secondary  infection,  these  enlarged  glands  do  not  break 
down  and  are  not  adherent  to  the  surrounding  tissues.  The  micro- 
scopic examination  of  sections  from  these  glands  reveals  marked 
changes  which  distinguish  them  from  the  enlarged  glands  of  lymphatic 
leukemia,  tuberculous  adenitis,  and  lymphosarcoma.  There  is  no 
leukocytic  infiltration,  although  eosinophiles  may  be  numerous.  There 
is  a  proliferation  of  endothelial  cells,  with  the  formation  of  lymphoid 
and  giant  cells.  An  increase  of  the  connective-tissue  stroma  is  observed 
in  the  more  advanced  cases,  which  accounts  for  the  hardening  of  the 
glands.  The  spleen  is  enlarged,  sometimes  to  a  great  extent,  and 
contains  lymphatic  nodules.  The  liver  and  kidneys  are  also  increased 
in  size,  and  the  site  of  lymphoid  deposits.  The  bone-marrow  may  show 
changes,  and  lymphoid  tissue  may  be  present.  Skin  tumors  are 
occasionally  seen.  No  specific  organism  has  been  isolated  from  the 
enlarged  glands  of  Hodgkin's  disease,  but  many  observers  have  found 
a  diphtheroid  bacillus. 

Symptoms. — Enlargement  of  the  superficial  lymph  glands,  usually  in 
the  neck,  is  commonly  the  first  complaint.  Other  glands  quickly 
show  enlargement,  but  they  are  not  painful.  With  the  progress  of 
the  disease,  enlargement  of  the  spleen  and  liver,  with  an  increasing 
anemia,  occurs.  The  patient  grows  weaker  rapidly  and  complains 
of  headaches,  vertigo,  palpitation,  and  dyspnea.  The  circulation 
becomes  poor,  and  edema  occurs  in  the  dependent  portions  of  the 
body.  Gastro-intestinal  disturbances  follow  with  constipation,  as  a 
rule,  and  sometimes  nausea  and  vomiting.  Ecchymoses  of  the  skin 
and  hemorrhages  from  the  mucous  membranes  occur.  Fever  is 
irregular  and  subsides  during  remissions.  Cachexia  develops  late,  and, 
commonly  wdth  it,  various  symptoms  from  pressure  of  the  enlarged 
glands  on  nerves  and  vessels  (Figs.  34  and  35). 

Blood  Pictm^e. — Early  in  the  disease  the  blood  may  show  no  change, 
but  with  the  onset  of  the  secondary  anemia  there  is  a  steady  fall  in 
hemoglobin.  The  color  index  is  low  since  the  red  cells  are  not  decreased 
in  proportion  to  the  hemoglobin.  There  is  no  increase  in  white  cells 
in  uncomplicated  cases,  but  there  may  be  a  lymphocytosis. 

In  the  event  of  a  complicating  tuberculous  infection  of  the  glands 
there  is  a  tendency  toward  high  leukocyte  counts  which,  if  the  process 
be  mixed,  as  it  often  is,  affects  chiefly  the  polynucleated  types  of  cells. 

Diagnosis. — The  diagnosis  is  based  upon  the  enlargement  of  the 
lymph  glands,  their  histological  structure,  and  the  accompanying  blood 


486  DISEASES  OF  THE  BLOOD 

picture.      The  structure  of  the  enlarged  glands  and  their  movability 
eliminate  lymphosarcoma.     Tuberculous  adenitis  generally  goes  on  to 


Fig.  34. — Hodgkin's  disease. 


Fig.  35. — Hodgkin's  disease. 


suppuration,  and  there  are  usually  other  foci  of  tuberculosis  present. 
Leukemia  is  excluded  by  the  blood  findings.     No  positive  conclusion  is 


HEMORRHAGIC  DISEASES  487 

justified  without  a  careful  microscopic  study  of  an  incised  section  of 
a  gland. 

Prognosis. — Since  there  is  no  successful  remedial  procedure  known, 
the  prognosis  is  uniformly  bad.  The  disease  is  fatal  in  from  a  few 
months  to  three  or  four  years  at  the  longest.  Death  finally  comes  on 
from  exhaustion  with  general  edema,  hastened  sometimes  by  a  com- 
plicating tuberculosis. 

Treatment. — Few  measures  give  any  relief  and  those  which  have  any 
appreciable  effect  are  only  temporary  in  their  results.  Hygienic 
surroundings,  fresh  air  and  good  food  exercise  their  beneficial  influence. 
Arsenic,  in  the  form  of  Fowler's  solution,  is  most  widely  used.  Tonics 
containing  iron,  strychnine,  cod-liver  oil,  and  quinine  are  recommended. 
Phosphorus  may  be  given  cautiously  in  doses  from  yito  to  yfo  of  a 
grain.  Glandular  extracts  and  bone  marrow  have  been  given  with 
indifferent  results.  Local  applications  bring  temporary  relief.  It  is 
claimed  that  the  Roentgen  rays  influence  certain  selected  cases.  Sur- 
gery is  of  no  avail  except  that  it  may  be  resorted  to  early  for  the 
removal  of  a  chain  of  enlarged  cervical  glands. 

HEMORRHAGIC   DISEASES. 

In  this  group  of  blood  diseases  we  include  those  with  hemorrhage 
as  the  dominating  feature,  and  caused  solely  by  changes  in  the  blood 
or  circulatory  apparatus.  Hemorrhage,  especially  in  infants,  may  be 
merely  symptomatic  of  an  anemia,  syphilis,  scurvy,  or  the  various 
infectious  diseases.  The  etiology  of  the  true  hemorrhagic  diseases, 
however,  is  obscure,  and  their  infectious  nature  or  endogenous  toxic 
origin  is  not  yet  proven.  An  overabundance  of  blood  and  a  lessened 
coagulability  of  the  blood  have  also  been  suggested  as  possible  causes. 
These  diseases  are  classified  as  hemophilia,  which  has  a  persistent  ten- 
dency to  hemorrhage  and  a  distinct  hereditary  basis;  and  as  purpuras, 
in  which  the  tendency  to  hemorrhage  is  only  transitory. 

Hemophilia  (Bleeder's  Disease). — This  is  an  inherited  disease  in 
which  the  individual  shows  a  disposition  to  alarming  and  persistent 
hemorrhage  from  trivial  abrasions  or  lacerations  and  spontaneous 
bleeding  from  no  demonstrable  cause. 

Etiology. — The  hereditary  nature  of  this  disease  is  well  established 
and  very  rarely  does  a  case  present  itself  where  this  may  not  be  brought 
out.  The  transmission  of  this  disease  is,  moreover,  along  definite  lines. 
In  a  family  of  bleeders,  the  female  members  transmit  the  disease  and 
the  males  manifest  it.  Thus,  a  girl  whose  mother  is  a  bleeder  will  not 
show  signs  of  the  disease,  but  will  transmit  it  to  her  children;  while 
•her  brother  will  be  a  bleeder  himself,  yet  his  children  by  a  healthy 
wife  will  not  be  bleeders,  although  his  grandsons,  through  his  daughters, 
may  suffer  from  the  disease.  The  tendency  to  transmit  hemophilia 
is  no  stronger  in  a  woman  from  a  family  of  bleeders,  who  herself  is 
a  bleeder,  than  in  her  sister,  who  may  not  be  a  bleeder.  Marriage,  to 
individuals  who  have  not  the  disease,  does  not  check  its  transmission, 


488  DISEASES  OF  THE  BLOOD 

and  more  than  50  per  cent,  of  the  children  in  the  affected  families 
inherit  hemophilia.  Large  families  have  been  the  rule  in  the  cases 
studied  and  traced  through  generations.  It  is  rarely  noticed  at  birth, 
but  most  cases  are  seen  during  childhood,  generally  before  the  second 
year.  They  usually  die  of  hemorrhage  before  the  tenth  year;  after 
the  twentieth  year  this  disease  is  exceedingly  rare.  It  is  observed 
more  often  in  boys  since  girls  are  not,  as  a  rule,  actual  bleeders.  Most 
of  the  cases  reported  have  been  in  Germans  and  Jews.  This  disease  is 
unknown  in  the  tropics,  and  occurs  most  frequently  in  temperate  climates. 

Pathology. — The  findings  at  postmortem  are  vague  and  indefinite. 
The  cause  of  the  fatal  hemorrhage  may  not  be  found.  There  may  be  an 
endarteritis,  fatty  degeneration  of  the  intima,  and  thinning  of  the  vessel 
walls.  A  secondary  anemia  may  be  present  as  a  result  of  the  hemor- 
rhages, but  the  only  blood  change  is  a  lessened  coagulability. 

Symptoms. — The  most  significant  symptom  is  bleeding  of  a  serious 
nature  from  slight  injury  or  no  apparent  cause.  This  may  be  a 
severe  sudden  hemorrhage,  or  a  constant  oozing  of  blood  which  resists 
all  attempts  to  check  it.  Such  trivial  injuries  as  the  extraction  of  a 
tooth,  or  even  dentition,  may  give  rise  to  prolonged  bleeding  of  a  serious 
aspect;  but  it  is  a  curious  fact  that  menstruation  and  childbirth  are 
not,  as  a  rule,  accompanied  by  great  loss  of  blood.  Spontaneous 
hemorrhages  occur  and  may  be  preceded  by  buzzing  in  the  ears,  great 
excitement  or  even  convulsions.  These  hemorrhages,  usually  of 
mucous  membranes,  take  place  in  the  gums,  nose,  throat,  or  bowel. 
Effusion  of  blood  into  the  joints  may  be  of  an  acute  nature  with  or 
without  fever,  or  it  may  be  chronic  with  some  limitation  of  motion 
and  even  ankylosis  resulting.  Following  these  hemorrhages,  we  have 
symptoms  common  to  hemorrhage  from  any  cause,  and  if  it  be  a  fatal 
one  the  patient  dies  from  exhaustion.  Sometimes  death  is  preceded 
by,  or  occurs  during,  a  convulsion. 

Diagnosis. — A  distinct  hereditary  history  with  a  personal  history 
of  unusual  loss  of  blood  from  trivial  accidents  makes  the  diagnosis 
certain.  This  is  practically  all  the  data  obtainable  in  the  average  case, 
and  the  lack  of  other  clinical  findings  excludes  other  diseases.  Blood 
examination  rules  out  anemias  and  leukemias.  Hemophilic  blood-clots 
in  from  two  and  one-half  to  five  hours,  the  delay  being  attributed  to 
an  excessive  antithrombin  blood  content,  due  to  actual  reduction  of 
prothrombin,  the  ultimate  factor  of  which  is  referable  to  some  altered 
function  of  the  platelets.  Scurvy  may  be  suggested,  but  diet  will 
quickly  relieve  that  condition  and  has  no  effect  on  hemophilia. 
Hemorrhages  of  the  newborn  are  different  in  nature,  and  purpuras  are 
accompanied  by  systemic  manifestations. 

Prognosis. — The  final  outcome  is  death  in  over  85  per  cent,  of  cases. 
The  longer  the  patient  survives,  the  better  the  prognosis,  and  after 
puberty  it  is  good.  The  death-rate  is  higher  in  males  than  in  females. 
Each  hemorrhage  may  be  the  last,  and  the  patient  recovers  from  one 
only  to  have  another,  until  the  final  one,  which  is  suddenly  overwhelm- 
ing or  absolutely  uncontrollable. 


HEMORRHAGIC  DISEASES  489 

Treatment. — Prophylaxis  is  essential,  and,  with  this  view,  some 
observers  have  claimed  that  the  women  of  affected  families  should  not 
marry.  The  patient  should  be  guarded  from  birth  and  carefully 
protected  to  prevent  any  abrasions  of  the  skin  and  mucous  membrane. 
Removal  to  the  tropics  should  always  be  suggested.  Operative  pro- 
cedures are  contraindicated  and  only  surgical  operations  to  save  life 
should  be  allowed.  If  operation  is  imperative,  a  careful  study  of  the 
coagulability  of  the  blood  should  precede  it,  and  an  attempt  made  to 
have  the  coagulation  period  as  near  normal  as  possible  at  the  time 
of  operation.  This  may  be  accomplished  by  intravenous  or  sub- 
cutaneous injections  of  human  blood  serum,  or,  if  time  permits,  thyroid 
extract  may  be  given  over  a  short  period.  In  the  event  of  hemorrhage, 
styptics  may  be  used  locally,  of  which  tannic  acid  and  the  perchloride 
of  iron  are  perhaps  most  serviceable.  Adrenalin  chloride  may  be 
given  internally  and  applied  locally.  I  have  obtained  good  results 
from  the  administration  of  calcium  lactate  in  the  dose  of  15  grains  three 
times  daily  in  a  case  of  persistent  epistaxis.  Other  drugs  which  should 
be  given  are:  tincture  of  chloride  of  iron,  jMonsel's  solution,  per- 
chloride of  iron,  ergot,  and  sodium  sulphate  in  small  but  frequent 
doses.  Gelatin  has  been  given  for  hemorrhage  of  the  stomach,  but 
the  results  are  very  unsatisfactory.  Rectal  injections  of  lead  acetate 
have  been  resorted  to  in  intestinal  hemorrhage.  Sterile  gelatin  in  a 
5  per  cent,  solution  has  been  given  subcutaneously.  Blood  transfusion 
should  be  tried  and  the  father's  blood  be  used,  if  practicable.  Human 
serum  is  preferable,  but  animal  serum  may  be  used,  of  which  normal 
horse  serum  is  perhaps  the  best. 

Purpura. — Purpura,  although  a  blood  disease,  is  sometimes  classi- 
fied under  diseases  of  the  skin,  because  of  its  chief  clinical  feature,  which 
is  the  appearance  of  hemorrhages  in  the  skin.  The  areas  of  hemor- 
rhage vary  in  size  from  that  of  a  flea  bite  to  large  ecchymotic  spots. 
At  times  they  may  be  found  in  the  mucous  membranes  and  also  in  the 
viscera. 

Etiology. — Purpura  is  thought  to  be  caused  by  the  action  of  toxins 
on  the  blood  or  circulating  apparatus.  It  is  usually  secondary, 
sometimes  merely  symptomatic,  but  other  cases  are  apparently 
primary.  Hemorrhagic  disease  of  the  newborn,  ileocolitis,  jaundice, 
leukemia,  primary  and  secondary  anemias,  nephritis,  scurvy  and 
syphilis  are  largely  responsible  for  this  condition.  In  older  children 
it  appears  with  measles,  scarlet  fever,  smallpox,  diphtheria  and  cerebro- 
spinal fever,  and  renders  the  prognosis  bad.  It  is  common  in  septi- 
cemia, pyemia,  and  malignant  endocarditis.  The  administration  of 
such  drugs  as  antipyrin,  benzoic  acid,  chloral,  chloroform,  ergot,  the 
iodides  and  mercurials,  mineral  acids,  potassium  chlorate,  arsenic, 
belladonna,  copaiba,  phosphorus,  quinine  and  the  salicylates,  may  pro- 
duce purpuric  outbreaks.  An  attack  of  purpura  may  be  brought  on  by 
bites  of  snakes  and  insects,  and  the  toxins  liberated  in  ptomain  poison- 
ing and  jaundice  have  a  similar  action.  The  paroxysms  of  whooping- 
cough,  the  removal  of  splints,  or  even  epilepsy,  may  cause  it.     There 


490  DISEASES  OF   THE  BLOOD 

is  not  the  same  relation  between  neurotic  conditions  and  purpura  in 
children  as  in  adults,  and  it  is  rarely  seen  in  association  with  such  a 
condition  before  puberty.  Purpura  occurs  in  the  cachectic  states  of 
malignancy  and  atrophy  of  infancy.  It  is  said  to  be  a  disease  of  young 
life,  most  cases  occmring  before  the  age  of  fourteen.  In  a  certain 
number  of  cases  no  cause  is  assignable,  and  these  we  term  primary, 
but  the  existence  of  primary  purpura  is  not  proven. 

Pathology. — ^There  is  either  a  hemorrhagic  exudate,  an  escape  of 
blood  by  diapedesis  or  merely  a  transudation  of  blood  pigment  into 
the  tissues.  Lesions  of  the  surrounding  vessels,  such  as  endarteritis, 
and  fatty  and  hyaline  degeneration  have  been  found,  but  they  may  be 
caused  by  the  underlying  factor  of  the  purpura  and  it  is  doubtful 
whether  they  belong  to  the  pathology  of  piu-pm-a.  Stasis  and  embolism 
have  been  observed  in  the  surrounding  vessels,  near  hemorrhagic 
areas.  Visceral  changes  include  enlarged  spleen,  gastric  ulcers,  and 
hemorrhage  into  the  adrenals.  The  blood  picture  is  not  characteristic, 
but  usually  shows  a  secondary  anemia  with  or  without  a  leukocytosis. 
There  may  be  evidence  of  hemorrhage  into  the  joint  cavities. 

Diagnosis. — The  existence  of  purpm-a  is  easily  proven,  but  in  children 
the  various  forms  are  not  clearly  defined  and  a  positive  diagnosis  of 
any  one  form  is  not  always  possible.  Scurvy  is  sometimes  difficult 
to  differentiate  from  an  attack  of  purpura.  The  following  forms  are 
met  with  in  children ;  purpura  simplex,  purpura  hemorrhagica,  purpura 
rheumatica,  and  Henoch's  purpura.  The  fulminating  form,  purpura 
fulminans,  is  only  a  rapidly  fatal  case  of  the  hemorrhagic  type. 

Purpura  Simplex. — This  form  is  the  mildest  variety  met  with  and 
may  not  be  accompanied  by  any  prodromal  systemic  symptoms. 
The  hemorrhages  are  confined  to  the  skin. 

Symptoms. — If  there  be  any  prodromal  symptoms,  they  are  slight 
and  consist  of  general  malaise,  anorexia,  headache,  and  constipation  or 
diarrhea.  With  the  appearance  of  the  purpura,  which  usually  consists 
of  small  lesions  varying  in  size  from  that  of  a  flea  bite  to  the  diameter 
of  a  lead  pencil,  there  may  be  nausea  and  vomiting,  and  a  slight  rise  in 
temperature.  The  characteristic  feature  of  the  purpura  spot  is  its 
change  of  color,  first  to  purple,  then  to  brown,  and  finally  by  degrees 
to  yellow.  Successive  crops  may  appear,  the  first  of  which  is  usually 
seen  on  the  legs;  the  arms  are  next  involved,  and  the  lesions  are  most 
abundant  on  the  extensor  surfaces.  The  face  and  trunk  are  apt  to  be 
free  from  the  lesions,  and  if  the  mucous  membranes  are  involved 
bleeding  externally  does  not  occur. 

Diagnosis. — The  diagnosis  is  easily  made  by  the  appearance  of  the 
purpuric  spots,  with  little  or  no  systemic  symptoms.  Symptomatic 
purpura  is  eliminated  by  the  absence  of  any  apparent  cause,  and  the 
more  severe  forms  of  purpura  are  excluded  by  the  absence  of  their 
particular  systemic  symptoms. 

Prognosis. — This  is  guardedly  favorable.  The  attack  lasts  from  one 
to  four  weeks,  but  relapses  are  common. 


HEMORRHAGIC  DISEASES 


491 


Treatment. — The  patient  must  remain  in  bed  as  long  as  fresh  crops 
of  purpuric  spots  tend  to  appear,  for  the  duration  of  the  disease  can 
be  prolonged  by  exercise  and  even  walking  about  at  this  period.  The 
diet  should  be  light  but  nutritious,  and  contain  much  of  fruit  acids. 
Mineral  acids,  astringents  such  as  gallic  acid,  and  hamamelis  are 
indicated.     Adrenalin  chloride  and  calcium  lactate  are  also  used. 

Purpura  Hemorrhagica. — This  Js  a  more  severe  form  of  purpura, 
in  which  the  skin,  mucous  membranes,  and  even  the  viscera  are 
involved,  and  systemic  symptoms  are  marked. 

Symptoms. — Prodromal  symptoms  are  common,  and  include  chilli- 
ness, fever,  vertigo,  diarrhea,  and  anorexia.  The  hemorrhages  vary 
in  size  from  petechia  to  ecchymotic  spots  |  inch  in  diameter.  These 
may  be  light  or  dark  red,  do  not  disappear  on  pressure,  and  are  either 
painful  or  itch.  Free  bleeding  may  occur  from  any  mucous  membrane, 
and  hemorrhage  from  the  nose,  mouth,  throat,  stomach,  bowels,  lungs, 
or  kidneys  has  been  observed.  A  hemiplegia  has  occurred  from  an 
intercranial  hemorrhage  in  this  dis- 
ease. A  secondary  anemia,  often  of 
severe  degree,  is  produced  by  the 
loss  of  blood,  and,  as  a  result,  the 
patient  complains  of  dyspnea,  pal- 
pitation, headache,  backache,  and 
may  have  abdominal  pains.  A 
typhoid  state  may  ensue  with  pros- 
tration, dry  tongue  and  mouth, 
insomnia,  carphologia,  muttering 
delirium,  or  even  coma.  This  is 
apt  to  result  fatally.  When  the 
symptoms  come  on  rapidly  and 
the  patient  quickly  succumbs,  the 
attack  is  known  as  purpura  fulmi- 
nans  (Fig.  36). 

Diagnosis. — ^The  diagnosis  is  based  upon  the  presence  of  purpuric 
hemorrhages  from  the  skin  and  mucous  membranes,  and  severe  consti- 
tutional symptoms  which  may  or  may  not  indicate  visceral  hemorrhage. 
Joint  pains  are  not  marked,  if  present  at  all,  and  this,  with  the  absence 
of  urticaria,  excludes  the  rheumatic  t^-pe.  A  possible  hemophiliac 
phase  is  eliminated  by  the  lack  of  a  family  history  characteristic  of 
the  bleeder  and  the  freedom  from  previous  hemorrhage.  Abdominal 
crises  of  Henoch's  purpura  do  not  occur. 

Prognosis. — If  the  case  be  mild  a  favorable  prognosis  may  be  given 
guardedly.  The  weak  and  young  usually  succumb  and  the  tj^^hoid 
state  generally  bespeaks  a  fatal  outcome.  High  temperature  and 
copious  hemorrhages  are  unfavorable  signs. 

Treatment. — Rest  in  bed,  good  hygienic  surroundings,  fresh  air,  and 
a  light  nutritious  diet  containing  an  abundance  of  fruit  acids  are 
essential.  If  there  is  gastric  or  intestinal  hemorrhage,  orange  juice, 
peptonized  milk  and  gelatin  may  be  given.     Fowler's  solution  is  used 


Fig.  36. — Purpura  hemorrhagica. 


492  DISEASES  OF   THE  BLOOD 

in  severe  cases  and  a  tonic  containing  iron  is  best  for  the  secondary 
anemia  during  convalescence. 

Purpura  Rheumatica. — Children  rarely  suffer  from  this  type  of 
pm-pura,  which  is  characterized  by  the  eruption  of  purpuric  spots 
especially  about  the  large  joints,  by  polyarthritis  and  exudative  erythe- 
mata.  A  possible  relation  between  this  disease  and  rheumatic  fever 
is  often  claimed  because  of  the  arthritis  and  occasional  cardiac  involve- 
ment, but,  in  my  opinion,  several  infective  or  toxic  agents  may  be 
capable  of  producing  it. 

Symptoms. — Preceding  the  appearance  of  purpura,  there  is  usually 
slight  fever  and  often  sore  throat.  A  polyarthritis  follows,  which  is 
usually  in  the  joints  of  the  lower  extremities,  and  rarely  involves  those 
of  the  arms.  Urticaria  and  erythema  nodosum  are  frequently  associated 
with  the  arthritis,  and  there  may  be  marked  edema  of  the  lower  extremi- 
ties. The  joints  are  usually  swollen  and  boggy,  and  are  painful  and 
tender.  The  spleen  is  sometimes  enlarged.  Albuminuria  may  occur, 
but  the  nephritis  is  mild.  Abdominal  pain  and  tenderness  are  occa- 
sionally observed. 

Diagnosis. — This  is  easy  when  a  polyarthritis  and  urticaria 
accompany  a  purpura  with  but  slight  fever  and  a  sore  throat. 

Prognosis. — After  two  weeks  a  recovery  may  be  expected,  but 
relapses  may  prolong  the  attack  for  months.  The  ultimate  outcome 
is  good,  although  the  heart  may  be  permanently  affected  if  cardiac 
involvement  occurs. 

Treatment. — The  patient  should  be  kept  in  bed  and  the  same  hygienic 
and  dietetic  measures  as  for  purpura  simplex  should  be  carried  out. 
The  polyarthritis  should  be  treated  by  the  internal  administration  of 
salicylates  and  by  local  applications  to  the  affected  joints. 

Henoch's  Purpura. — Henoch's  purpura  or  abdominal  purpura  is 
most  frequent  in  children  and  the  symptoms  are  referable  to  the  skin, 
joints,  and  abdomen.  The  skin  lesions  are  usually  purpuric,  but  may 
also  consist  of  circumscribed  areas  of  edema  and  exudative  erythemata. 
The  joints  of  both  upper  and  lower  extremities  are  painful  and  swollen. 
The  abdominal  symptoms  are  gastro-enteric  crises  of  colic,  vomiting, 
tympanites,  and  tenesmus  with  melena.  There  may  be  hematuria 
and  albuminuria,  with  a  fatal  nephritis.  Occasionally  there  are 
cerebral  and  pulmonary  symptoms. 

Diagnosis. — The  abdominal  crises  occurring  in  a  case  of  purpura, 
with  joint  lesions,  are  indicative  of  Henoch's  purpura. 

Prognosis. — The  prognosis  is  grave  where  recurrence  is  frequent; 
the  mortality-rate  in  Osier's  series  was  25  per  cent. 

Treatment. — Rest  in  bed  with  the  same  hygienic  and  dietetic  treat- 
ment as  suggested  in  the  other  forms  of  purpura,  should  be  carried  out. 
Further  treatment  is  symptomatic.  The  calcium  salts  have  been  used 
where  hemorrhages  were  severe,  and  atropin  is  recommended  for  the 
abdominal  pain.  Local  applications  may  give  relief  to  abdominal  and 
joint  pains,  and,  if  the  arthritis  is  marked,  salicylates  should  be  admin- 
istered internally.  During  convalescence  iron  and  arsenic  in  tonic 
doses  are  of  special  value. 


CHAPTER  XVII. 
DISEASES  OF  THE  DUCTLESS  GLANDS. 

The  spleen  is  very  easily  aft'ected  by  disease  during  childhood, 
and  is  then  more  readily  palpable,  which  makes  it  of  greater  diagnostic 
value  in  children  than  in  adults.  Its  length  ranges  from  2  to  4  inches, 
according  to  the  age  of  the  child,  it  is  half  as  wide  as  it  is  long,  and 
about  i  of  an  inch  thick.  The  size  of  the  spleen  varies  greatly  with 
the  state  of  the  nutrition.  As  a  rule,  a  poorly  nourished  infant  will 
have  a  very  small  spleen,  but  when  malnutrition  is  caused  by  syphilis 
or  rachitis  the  spleen  is  enlarged.  There  is  a  physiological  increase 
in  the  size  of  the  spleen  during  digestion,  owing  to  the  increased  amount 
of  blood  in  the  organ  at  this  time. 

The  position  of  the  spleen  may  be  made  out  by  percussion  with  the 
child  lying  on  its  back  and  percussing  above  downward  in  the  mid- 
axillary  line.  Splenic  dulness  will  be  found  to  extend  from  the  ninth 
to  the  eleventh  rib  and  from  the  posterior  axillary  line  to  a  little 
beyond  the  midaxillary  line.  In  infants  the  area  of  splenic  dulness 
m.ay  not  be  distinguishable,  m.ay  sometimes  be  obliterated  by  gastric 
or  colonic  tympany,  and  m.ay  be  simulated  by  fecal  m.asses  in  the  colon. 

In  order  to  palpate  the  spleen  the  patient  should  lie  on  his  back  with 
the  thighs  flexed  to  afford  good  relaxation  of  the  abdominal  muscles. 
The  physician's  hand  should  be  warmed,  and  should  first  be  gently 
placed  over  the  splenic  area,  just  at  the  lower  border  of  the  ribs, 
until  abdominal  rigidity  is  overcome.  The  right  hand  is  preferable, 
the  examiner  standing  on  the  right  side  of  the  patient.  The  finger 
tips  are  pressed  up  under  the  costal  margin  between  the  posterior 
and  midaxillary  lines,  when  the  spleen  should  be  felt  touching  the 
finger  tips  with  each  respiration.  The  edge  of  the  spleen  should  be 
felt  just  under  the  lower  border  of  the  ribs.  If  it  extends  below  the 
costal  m.argin  it  is  enlarged. 

Enlargement  of  the  spleen  may  be  acute  or  chronic;  in  children 
acute  enlargement  is  much  more  frequent  than  in  adults,  since  many 
of  the  acute  infectious  diseases  cause  an  increase  in  its  size,  A 
chronically  enlarged  spleen  is  seen  in  malaria,  cirrhosis  of  the  liver, 
the  chronic  infectious  diseases,  particularly  syphilis  and  tuberculosis, 
and  in  chronic  congestion  caused  by  cardiac  and  pulmonary  disease. 
The  spleen  is  also  enlarged  in  the  various  forms  of  anemia,  in  Hodgkin's 
disease,  gastro-enteritis,  acute  catarrhal  jaundice,  and  amyloid  de- 
generation. 

SPLENITIS. 

Inflammation  of  the  spleen  is  rare,  and  when  it  occurs  is  generally 
caused  by  extension  from  surrounding  structures,  such  as  the  stomach, 


494  DISEASES  OF  THE  DUCTLESS  GLANDS 

diaphragm,  lungs,  or  the  perinephric  tissue.  It  may  be  due  to  trauma. 
In  splenitis  the  spleen  is  found  to  be  enlarged,  percussion  in  the  splenic 
region  is  painful,  and  palpation  reveals  acute  tenderness.  The  diagnosis 
is  based  on  the  s}Ti].ptom.s  outlined  above,  with  a  history  of  traum.a 
or  inflammation  of  surrounding  structures. 

PERISPLENITIS. 

Perisplenitis  is  an  inflam.m.ation  of  the  serous  covering  of  the  spleen. 
It  occurs  in  general  peritonitis,  and  may  also  be  a  result  of  extension 
from,  an  ulcer  of  the  stom.ach,  a  left  diaphragm.atic  pleurisy,  peri- 
nephric inflam.m.ation,  or  chronic  colitis.  Traum.a,  hemorrhagic  in- 
farcts, syphilis,  and  tuberculosis  are  am.ong  the  rare  causes  of  peri- 
splenitis. 

The  diagnosis  is  made  by  detecting  the  friction  rub  of  the  roughened 
capsule.  On  auscultation  the  friction  rub  is  heard  better  at  the  lower 
m.argin  of  the  rib  than  over  the  chest  wall,  and  this  helps  to  differentiate 
it  from  a  pleural  friction  rub.  In  some  cases  the  spleen  m.ay  be  iro.mov- 
able  owing  to  adhesions. 

ABSCESS  OF  THE  SPLEEN. 

This  is  a  rare  condition  in  children,  but  may  arise  from  trauma  or 
during  the  course  of  malaria,  typhoid  fever,  or  pyemia.  It  may  also 
be  due  to  extension  from,  a  suppurative  process  in  adjacent  tissues. 
When  the  suppurative  lesion  reaches  the  surface  perisplenitis  results, 
and  rupture  usually  follows,  the  contents  pouring  into  the  free  peri- 
toneal cavity  or  som.e  adjacent  viscus. 

WANDERING  SPLEEN. 

As  the  result  of  elongation  of  the  gastrosplenic  ligament  and  the 
splenic  artery  and  vein,  the  spleen  may  attain  a  wide  range  of  mova- 
bility.  When  this  condition  exists  there  is  tym.pany  over  the  area  of 
norm.al  splenic  dulness,  and  abdom.inal  palpation  reveals  the  spleen 
low  down  in  the  abdom.en,  but  usually  on  the  left  side.  As  a  rule  it 
can  be  replaced,  but  when  the  patient  assum.es  the  upright  position 
it  will  again  fall  out  of  place. 

The  m.ost  constant  sym.ptom.  is  a  dragging  sensation  in  the  abdomen. 
The  spleen  is  enlarged,  and  may  produce  sym.ptom.s  by  pressure  on  the 
ureter,  bladder,  or  bowel,  and  there  are  usually  nervous  sym.ptoms  like 
those  accompanying  nephroptosis.  The  presence  of  a  fecal  tum.or  or  a 
floating  kidney  m.ust  be  considered  and  excluded  before  a  positive 
conclusion  is  reached.  The  treatment  consists  of  mechanical  m.easures 
to  keep  the  spleen  in  its  proper  position,  but  they  are  only  moderately 
successful. 


SIMPLE  ACUTE  ADENITIS  495 

PRIMARY  SPLENOMEGALY. 

This  is  a  rare  form  of  enlargement  of  the  spleen,  which  is  most 
common  in  children.  The  cause  is  unknown.  There  is  hyperplasia 
of  the  endothelial  cells  of  the  spleen,  with  changes  in  the  m.esenteric 
lymph  nodes.  The  liver  is  enlarged  secondarily,  and  contains  an 
increased  am.ount  of  connective  tissue.  There  are  abdominal  pains 
and  gastro-intestinal  disturbances.  Simple  anemia  with  subcutaneous 
hem.orrhages  and  bleeding  from  the  gum.s  and  nose  may  be  present. 
Dyspnea  and  dysuria  have  been  noted.  The  spleen  m.ay  attain  such 
a  size  as  practically  to  fill  the  abdominal  cavity. 

NEW  GROWTHS  OF  THE  SPLEEN. 

In  children  the  spleen  is  rarely  the  site  of  new  growths,  but  occasion- 
ally the  roughened  or  nodular  surface  of  the  spleen  will  warrant  their 
consideration.  Tuberculosis  is  the  m.ost  com.m.on  cause  of  nodular 
spleen  in  children.  Gum.m.ata  of  the  spleen  are  rare,  although  the 
enlarged  spleen  is  the  m.ost  constant  sign  of  hereditary  syphilis. 
Leprosy,  actinomycosis,  and  parasitic  cysts  have  been  observed. 
Benign  splenic  tumors  are  very  rare.  Of  the  malignant  tum.ors, 
sarcom.as  are  the  most  frequently  found,  and  are  usually  secondary. 
Cancer  is  extrem.ely  rare. 


DISEASES  OF  THE  LYMPH  GLANDS. 

Enlarged  lymph  glands  are  m.uch  m.ore  com.mon  in  children  than 
in  adults,  and  of  all  the  lymph  nodes  in  the  body  the  cervical  glands 
are  the  most  frequently  enlarged.  Pediculosis  capitis,  or  disease  of  the 
scalp,  such  as  an  eczematous  condition,  causes  enlargement  of  the 
posterior  cervical  glands.  The  anterior  cervical  glands  becom.e  enlarged 
with  disease  of  the  nose  and  throat,  and  are  also  subject  to  infection 
by  the  tubercle  bacillus.  The  axillary  glands  are  involved  by  infection 
of  the  arm  and  outer  side  of  the  upper  chest  wall. 

Enlargement  of  the  epithrochlears  is  seen  in  syphilis.  The  inguinal 
glands,  which  are  the  only  set  norm.ally  palpable,  are  enlarged  when 
there  is  a  lesion  of  the  genitalia  or  infection  of  the  leg.  General 
glandular  enlargem.ent  is  observed  in  syphilis,  tuberculosis,  lym.phatism, 
the  various  form.s  of  anemia,  and  following  acute  infectious  diseases. 
Children  of  lymphatic  diathesis  rarely  exhibit  it  after  adolescence. 

SIMPLE  ACUTE  ADENITIS. 

Children  are  very  susceptible  to  simple  adenitis,  which  is  an  acute 
inflammation  of  the  lymph  nodes.  The  cervical  glands  are  the  ones 
affected  in  over  80  per  cent,  of  the  cases;  they  become  inflamed  by  the 


496  DISEASES  OF  THE  DUCTLESS  GLANDS 

draining  of  an  infected  area,  such  as  a  diseased  tonsil  or  a  decayed 
tooth.  Acute  adenitis  may  complicate  the  acute  infectious  diseases, 
and  usually  appears  during  tonsillitis  or  any  throat  infection.  Eczema 
and  stomatitis  may  also  give  rise  to  acute  adenitis. 

The  deep  lymphatic  glands  may  become  inflamed  from  draining  an 
infected  source,  but  they  are  not  demonstrable,  hence  only  the  super- 
ficial glands  will  be  considered.  The  axillary  and  inguinal  glands 
enlarge  when  there  is  infection  of  those  areas  of  the  body  which  they 
drain.  Most  cases  of  simple  adenitis  occur  before  two  years  of  age. 
The  exciting  or  direct  cause  is  the  entrance  of  pyogenic  organisms  into 
the  lymph  glands. 

Pathology. — The  enlargement  of  the  gland  is  due  to  hyperplasia"  of 
lymphoid  cells,  with  acute  congestion  of  the  glands.  The  infection 
may  go  this  far,  and  then  stop,  or  may  proceed  to  suppuration  according 
to  the  virulence  of  the  organism  and  the  resistance  of  the  patient. 

The  streptococcus  is  usually  isolated  in  those  cases  which  suppurate, 
although  the  staphylococcus,  pneumococcus,  gonococcus,  and  typhoid 
bacillus  have  also  been  found.  As  suppuration  takes  place  the  nodes 
become  softer  and  the  surrounding  tissue  infiltrated  which  causes 
cellulitis.  Frequently  only  one  node  in  a  chain  of  several  diseased 
ones  will  suppurate. 

Symptoms. — Swelling  just  below  the  angle  of  the  jaw  is,  perhaps, 
the  first  sign  of  cervical  adenitis.  The  degree  of  tenderness  varies; 
in  some  cases  there  is  very  little  pain,  while  in  others  merely  moving 
the  jaw  is  painful.  There  is  moderate  fever,  with  symptoms  of  the 
underlying  disease  if  adenitis  is  caused  by  one  of  the  acute  infections. 
Suppuration  takes  place  between  the  first  and  fourth  weeks;  after 
the  fourth  week,  if  there  has  been  no  suppuration,  resolution  may  be 
expected  to  follow  the  stage  of  hyperplasia.  The  glands  becom.e 
smaller  and  harder,  and  slowly  return  to  their  normal  size.  After 
repeated  infections  the  gland  may  become  chronically  enlarged,  and 
remains  as  a  palpable  nodule  throughout  life. 

Upon  inspection  only  one  or  two  glands  in  the  chain  will  appear  to 
be  affected,  but  palpation  shows  the  whole  chain  to  be  involved.  When 
suppuration  begins  the  gland  softens,  the  overlying  skin  becomes  red, 
and  tenderness  and  pain  are  increased.  If  not  lanced  there  is  pointing 
and  rupture  through  the  skin,  with  the  discharge  of  a  creamy  pus. 
This  relieves  the  symptoms,  and  there  is  slow  recovery,  with  an  ugly 
scar  at  the  site  of  rupture. 

Diagnosis. — Acute  adenitis  may  simulate  mumps,  but  in  mumps 
the  swelling  is  in  the  parotid  region,  the  lobe  of  the  ear  forming  the 
centre  of  the  swelling.  In  mumps  there  is  usually  a  history  of  contact, 
and  in  adenitis  a  history  of  some  preceding  nose  or  throat  condition. 
After  two  years  of  age  tuberculous  adenitis  is  quite  frequent,  but 
may  be  ruled  out  by  its  chronicity. 

Treatment. — The  cause  should  be  ascertained  and  removed  if 
possible.  Careful  attention  to  the  throat,  especially  to  the  tonsils 
and  any  adenoids,  will  prevent  most  cases  of  cervical  adenitis.    Locally, 


SIMPLE  CHRONIC  ADENITIS  497 

cold  applications  will  give  relief,  and  are  indicated  if  there  is  m.erely 
congestion  and  swelling  with  no  suppuration.  Cold  compresses  are 
better  than  an  ice-bag,  but  should  be  renewed  every  fifteen  to  twenty 
minutes. 

When  suppuration  becomes  inevitable,  heat  and  ichthyol  ointment 
should  be  applied.  If  there  is  fluctuation  the  abscess  should  be  opened 
and  drained.  A  course  of  calomel  should  be  followed  by  magnesium 
sulphate,  and  then  syrupi  ferri  iodidi  given  in  full  doses  for  a  period 
of  weeks.  For  those  glands  which  do  not  suppurate,  but  which  remain 
large  and  later  offer  but  poor  resistance  to  the  tubercle  bacillus,  the 
iodides,  electricity,  Bier's  hyperemia,  or  surgical  removal  may  be 
resorted  to. 

SIMPLE  CHRONIC  ADENITIS. 

This  is  usually  a  mild  degree  of  enlargement  of  the  lymph  glands, 
which  persists  in  conseqirence  of  repeated  attacks  of  acute  adenitis 
or  because  the  source  of  infection  is  still  acute.  Chronic  nose  and 
throat  conditions  and  chronic  skin  or  scalp  diseases  are  frequently 
responsible  for  the  persistent  enlargement  of  these  glands.  As  a  rule, 
hypertrophied  tonsils  and  adenoids  are  present,  and,  possibly,  that 
condition  known  as  status  lym.phaticus. 

Symptoms. — Enlargement  of  the  glands  is  the  main  clinical  feature. 
Pain  and  tenderness  are  absent,  and  there  are  no  constitutional 
symptoms.  The  glands  m.ay  remain  enlarged  for  m.onths,  or  even  years, 
or  m.ay  never  return  to  normal,  those  affected  remaining  as  small  hard 
nodules  throughout  life.  Suppuration  does  not  take  place  in  these 
glands,  but  the  centre  of  the  gland  may  be  found  to  consist  of  broken- 
down  tissue  resem.bling  tuberculous  caseation. 

Diagnosis. — Simple  chronic  adenitis  must  be  differentiated  from 
tuberculous  adenitis  and  Hodgkin's  disease.  The  absence  of  any 
clinical  features  other  than  enlargement  of  the  glands,  th-e  age  of  the 
individual,  and  the  slow  progress  of  the  process  usually  favor  simple 
chronic  adenitis. 

If  we  suspect  som.e  specific  factor  rather  than  simple  chronic  enlarge- 
ment of  the  glands,  an  incised  section  examined  under  the  microscope 
will  reveal  the  true  nature  of  the  disease.  The  importance  of  diagnosing 
a  possible  tuberculous  adenitis  early  is  so  great  that  a  section  of  the 
suspected  gland  should  be  made  in  every  case  where  doubt  exists 
as  to  whether  or  not  surgery  should  be  resorted  to. 

Treatment. — Removal  of  the  cause  of  the  enlargement  is  essential 
before  improvement  can  be  expected.  Potassium  iodide  and  the  syrup 
of  the  iodide  of  iron  should  be  given  in  full  doses.  Cod-liver  oil  and 
arsenic  in  the  form  of  Fowler's  solution  are  both  beneficial  for  their 
tonic  eftect.  An  outdoor  life,  with  plenty  of  exercise  and  good  nourish- 
ing food,  will  m.aterially  hasten  the  ultimate  recovery.  In  view  of  the 
fact  that  these  glands,  if  they  remain  enlarged,  frequently  become 
tuberculous,  surgical  removal  should  be  advised  when  other  treatment 
is  of  no  avail. 
32 


498  DISEASES  OF  THE  DUCTLESS  GLANDS 

TUBERCULOUS  ADENITIS. 

The  term  "tuberculous  adenitis"  is  awarded  by  common  usage  to 
tuberculosis  of  the  cervical  lymph  glands.  The  infecting  organism 
gains  access  to  the  glands  through  abrasions  or  the  extension  of 
inflammation  in  the  mucous  membrane  of  the  nose  and  •  throat. 
Diseased  tonsils,  adenoids,  and  chronic  inflammation  of  the  naso- 
pharynx predispose  to  the  tuberculous  infection. 

It  is  now  believed  that  the  bacilli  do  not  penetrate  the  normal  mucous 
membrane,  but  are  carried  in  with  food  and  air,  and  obtain  access 
through  the  point  of  least  resistance,  which  is  usually  the  site  of  some 
chronic  inflammation.  In  uncomplicated  cases  the  infecting  organism 
is  often  difficult  to  find.  It  is  usually  the  human  type  of  the  tubercle 
bacillus,  although  the  bovine  form  has  been  isolated. 

Suppuration  is  generally  caused  by  mixed  infection  with  the  strepto- 
coccus. Merely  one  chain  of  glands  or  the  lymphatics  on  both  sides  of 
the  neck  may  be  affected.  In  some  cases  all  of  the  glands  of  the  body 
may  be  involved — the  cervical  first,  then  the  axillary,  mediastinal, 
retroperitoneal,  mesenteric,  and  inguinal  glands. 

The  disease  may  progress  in  such  a  manner  as  to  bear  a  resemblance 
to  Hodgkin's  disease.  The  glands  may  appear  as  separate  and  discrete 
nodes,  varying  in  size  from,  that  of  a  bean  to  a  walnut,  or  they  may 
coalesce.  They  may  be  quite  hard  or  almost  gelatinous  in  consistency. 
An  incised  gland  will  be  found  to  contain  an  increased  amount  of 
connective  tissue,  with  m.any  small  areas  of  necrosis  throughout  its 
substance.  Microscopically,  giant  cells  containing  several  nuclei 
may  be  seen;  the  tubercle  bacillus  is  hard  to  demonstrate.  Caseation 
does  not  occur  in  this  generalized  adenitis. 

Symptoms. — As  a  rule,  there  are  no  constitutional  symptoms  and 
the  health  may  apparently  be  unaffected;  usually,  however,  there  is  a 
gradual  loss  of  weight  with  mild  secondary  anemia.  If  there  is  second- 
ary infection  of  the  glands,  slight  fever  is  noted  and  the  glands  are 
painful.  Those  glands  situated  at  the  angle  of  the  jaw  first  become 
enlarged,  and  this  swelling  may  be  the  only  noticeable  sign  of  tuber- 
culous adenitis.  The  swelling  is  usually  unilateral,  but  may  involve 
both  sides. 

As  the  disease  progresses  the  glands  become  iro.movable  from,  the 
periadenitis  which  develops,  and  adhesions  to  the  surrounding  tissues 
form.  There  is  practically  no  pain  in  uncomplicated  cases.  With 
secondary  infection  and  pus  formation  the  usual  symptoms  of  abscess 
are  present. 

If  the  gland  is  not  incised  at  this  stage,  the  abscess  m.ay  rupture 
through  the  skin,  or  rupture  beneath  it  and  the  pus  burrow  down 
through  the  fascia  of  the  neck,  collecting  at  the  most  dependent  part, 
and  there  escape  through  the  skin.  When  this  occurs  there  is  a  fistula 
between  the  infected  gland  and  the  point  where  it  opens  through  the 
skin.  The  whole  process  is  essentially  chronic,  only  the  neglected 
cases  resulting  in  ruptured  abscesses  and  fistula  formations. 


DISEASES  OF  THE  THYMUS  GLAND  499 

Diagnosis. — Tuberculous  adenitis  must  be  differentiated,  first,  from 
simple  chronic  adentitis.  The  age  of  the  child,  the  tuberculin  reaction, 
and  the  presence  or  absence  of  other  tuberculous  lesions  must  be  taken 
into  consideration  in  determining  with  which  of  these  forms  of  adenitis 
we  are  dealing.  If  lymphosarcoma  or  pseudoleukemia  is  suspected, 
a  section  of  the  enlarged  gland  should  be  examined  microscopically. 
Examination  of  the  blood  will  rule  out  the  possibility  of  leukemia 
as  a  cause  of  the  glandular  enlargement. 

Prognosis. — The  prognosis  of  tuberculous  adenitis  is  better  than  for 
any  other  form  of  tuberculosis,  since  the  infected  tissue  is  easy  of 
access,  and  the  disease  tends  to  remain  localized.  Systemic  infection 
from  foci  in  the  glands  of  the  neck  is  rare,  hence  the  mortality-rate  of 
tuberculous  adenitis  is  extremely  low.  If  the  case  is  diagnosed  early, 
and  its  surgical  removal  undertaken,  recovery  with  complete  eradica- 
tion of  the  disease  may  be  expected. 

Treatment. — Early  and  complete  removal  of  all  the  infected  glands 
is  unquestionably  the  only  safe  treatment  of  tuberculous  adenitis.  In 
the  hands  of  a  skilful  surgeon  there  need  be  no  appreciable  scar  after 
the  operation,  although  through  fear  of  disfigurement  many  parents 
will  object  to  operative  procedure.  Following  the  operation  the  patient 
should  have  the  advatage  of  the  routine  treatment  for  tuberculosis 
with,  possibly,  a  change  of  climate. 

The  diet  should  be  wholesome  and  nutritious,  with  an  abundance  of 
eggs  and  milk.  Cod-liver  oil  is  of  great  benefit,  but  care  should  be 
taken  that  it  does  not  impair  the  appetite.  The  syrup  of  the  iodide 
of  iron  should  be  given  in  full  doses  throughout  convalescence,  and 
arsenic  in  the  form  of  Fowler's  solution  is  indicated  for  the  secondary 
anemia  which  is  usually  present. 


DISEASES   OF  THE   THYMUS   GLAND.       ' 

The  thymus  gland  is  a  lymphoid  structure  which  exists  only  during 
childhood,  the  period  of  its  greatest  growth  being  reached  at  the  end 
of  the  second  year.  Atrophy  of  the  lymphoid  tissue  with  an  increase 
in  the  fibrous  and  adipose  tissue  takes  place  gradually  from,  the  second 
year  until  puberty.  From  puberty  on  to  early  adult  life  there  is 
rapid  atrophy  of  the  gland,  until  at  adult  life  there  exists  merely  a 
fibro-fatty  body  with  but  faint  traces  of  thymus  lymphoid  tissue. 
During  childhood  two  distinct  lobes  may  be  defined,  lying  in  close 
contact  with  the  pericardium,  and  the  trachea.  The  two  lobes  are 
unequal  in  size,  but  may  be  said  to  extend  from  the  lower  border  of  the 
thyroid  gland  to  the  level  of  the  fourth  costal  cartilage.  The  gland 
lies  just  beneath  the  sternum  in  the  chest,  and  farther  up  is  found  under 
the  sternohyoid  and  sternothyroid  muscles.  The  two  lobes  may  be 
united,  or  there  may  be  a  third  lobe.   The  average  weight  of  the  thymus, 


500 


DISEASES  OF  THE  DUCTLESS  GLANDS 


as  given  by  various  observers,  offers  a  wide  range,  but  to  the  best  of 
our  knowledge  the  normal  thymus  gland  should  weigh  from  7  to  10 
grams  (100  to  150  grains)  between  birth  and  two  years  of  age.    It 


is 


Fig.  37 


Fig.  38 


Fig.  37.' — Unilobar  thoracic  thymus.  Newborn  infant,  death  from  causes  in  no 
way  referable  to  thymus.  Single-lobed  thymus  extended  from  just  below  interclavicular 
space  to  diaphragm  along  right  border  of  heart.  Weight  3.75  grams.  No  other  thymic 
tissue  found.  No  evidence  of  pressure  on  trachea;  position  such  that  trachea  could  not 
have  been  compressed.      (Coplin.) 

Fig.  38. — Bilobar  thoracic  thymus.  Status  lymphaticus  thymic  death.  Male, 
aged  fovirteen  years;  asthma  of  long  duration;  otherwise  in  good  health.  Received 
immunizing  dose  of  antitoxin;  death  in  a  few  minutes.  Notable  hyperplasia  of  many 
lymph  nodes.  Thymus  consists  of  two  tongue-like  lateral  lobes  extending  clownward 
over  heart  to  diaphragm;  no  median  lobe;  weight  17  grams.  Upper  margin  behind 
sternum  more  than  2  cm.  below  notch.  No  evidence  of  tracheal  compression.  Upper 
third  of  each  lobe  shows  wrinkled  capsule,  fat  infiltration  and  shrinkage — evidences 
of  regression.  The  absence  of  any  isthmus  or  mass  at  point  of  junction  precludes 
tracheal  pressure.      (Coplin.) 


1  Figs.  37  to  45  are  published  with  the  permission  of  Dr.  W.  M.  L.  Coplin,  and  are 
taken  from  his  article  on  "Morphology  of  the  Human  Thymus,"  Publications  from  the 
Jefferson  Medical  College  and  Hospital,  Philadelphia,  1915,  vol.  vi. 


DISEASES  OF  THE  THYMUS  GLAND 


501 


about  12  cm.  (5  inches)  long  and  from  f  to  U  inches  (2  to  3  cm.)  wide 
when  it  has  attained  its  largest  size. 


-.-•O 


Fig.  39 


Fig.  40 


Fig.  39. — -Trilobar  cervicothoracic  thymus.  Infant;  death  a  few  hours  after  birth, 
not  thought  to  have  been  due  to  thymus.  Long  median  lobe  extending  above  sternal 
notch ;  two  imperfectly  distinguishable  lateral  lobes,  the  inferior  margin  of  which  extended 
over  anterior  part  of  auricles  but  not  reaching  the  ventricles.  No  evidence  of  pressure 
on  vessels  or  trachea.     Weight  of  thymus  4.14  grams.      (Coplin.) 

Fig.  40. — ^Trilobar  cervicothoracic  thymus  (persistent).  Male,  colored,  aged  thirty- 
six  years.  Hemiplegia,  epilepsy,  aphasia.  Death  from  cerebral  softening.  Middle 
or  superior  lobe  abnormally  large;  lateral  lobes  about  normal  for  childhood,  extended 
from  above  suprasternal  notch  to  diaphragm.  Weight  of  thymus  7.82  grams.  No 
evidence  of  pressure.  Were  the  superior  lobe  large,  or  greatly  thickened  antero- 
posteriorly,  pressure  on  trachea  would  be  possible.     (Coplin.) 


Physiology. — The  function  of  the  thymus  is  not  yet  understood, 
and  we  are  still  in  doubt  as  to  whether  it  should  be  classed  as  one  of  the 
ductless  glands  or  with  the  other  lymphoid  structures  of  the  body. 


502 


DISEASES  OF  THE  DUCTLESS  GLANDS 


It  is  thought  to  be  connected  with  the  lymph  system  and  the  thyroid 
and  parathyroid  glands.  That  there  is  a  relation  between  the  thymus 
and  testes  is  shown  by  the  delayed  involution  of  the  thymus  following 
castration,  and  the  rapid  growth  of  the  testes  in  thymectomized  anim.als. 
Extirpation  of  the  thymus  is  also  followed  by  softening  of  the  bones 


Fig.  41  Fig.  42 

Fig.  41. — Trilobar  cervicothoracic  thymus.  Male,  white,  aged  thirteen  years. 
Splenic  anemia,  greatly  enlarged  spleen  weighing  1100  grams.  Splenectomy;  recovery. 
Two  years  later  admitted  to  hospital  in  convulsions,  probably  unconscious,  face  flushed, 
dyspnea,  respirations  40,  slight  cyanosis,  rapid  heart  (100).  Temperature  104°;  extremi- 
ties cold.  History  of  dog  bite.  Clinical  diagnosis:  Status  lymphaticus.  Postmortem: 
Status  lymphaticus;  congestion  of  lungs;  adhesive  pleuritis;  congestion  of  liver  and 
kidneys;  hyperplasia  of  lymphoid  tissue  of  intestine,  colon  and  stomach;  enlarged 
lymph  nodes;  chronic  adhesive  peritonitis  in  splenic  area;  adhesions  probably  due  to 
splenectomy.  Organ  of  quite  unusual  shape,  resting  upon  and  overlapping  heart  and 
extending  upward  behind  sternum  just  above  notch.  Weight  of  thymus  2.3.61  grams. 
Such  an  organ  might  press  upon  trachea  in  critical  space  or  beneath  sternum.  There  is 
sufficient  evidence  to  justify  the  recognition  of  lobes;  otherwise  it  might  be  called  a 
conglomerate  thymus  which  it  in  part  resembles.      (Coplin.) 

Fig.  42. — Conglomerate  thoracic  thymus.  Female,  colored,  aged  twenty  months. 
Clinical  note:  Bronchopneumonia,  pleurisy;  dyspnea;  cyanosis;  rapid  pulse  of  low 
tension.  Postmortem:  Bronchopneumonia,  bilateral  pleural  effusion,  partial  atelectasis, 
congestion  of  liver  and  spleen ;  fatty  infiltration  of  liver.  Thymus  lies  over  and  anterior 
to  heart,  is  thin,  of  rather  flat  type,  lobes  imperfectly  and  irregularly  joined  above  and 
below.     Weight  9  grams.      (Coplin.) 


and  cessation  of  their  growth,  by  an  increased  electrical  excitability  of 
the  peripheral  nervous  system,  increased  fat  absorption,  malnutrition, 
and  cachexia.  Enlargement  of  the  spleen  is  followed  by  shrinking  of 
the  thymus.  Bourneville  found  the  thymus  in  only  27  per  cent,  of 
idiots  at  postmortem.    In  addition  to  this  relation  of  the  thymus  to 


Fig.  43. — Conglomerate  thoracic  thymus.  Female,  white,  aged  one  year.  Clinical 
diagnosis:  Bronchopneumonia.  Postmortem:  Bronchopneumonia.  Patent  intra- 
ventricular septum;  chronic  mitral  endocarditis;  hypertrophy  and  dilatation  of  left 
ventricle.  Congestion  of  liver,  spleen  and  kidneys.  Pyramidal  or  conic  thymus;  lobu- 
lation imperfect,  somewhat  flattened  anteroposteriorly ;  pale,  some  edema;  organ  firm, 
pressure  phenomena  improbable.     Weight  of  thymus  16.3  grams.      (Coplin.) 


/  c  «;  \' 


Fig.  44 


Fig.  45 


Fig.  44. — Conglomerate  cervicothoracic  thymus.  Eclamptic  mother  died  suddenly 
following  therapeutic  administration  of  horse  serum.  Infant  (seven  months?)  obtained 
postmortem;  length  46  cm.,  weight  2020  grams.  Subpericardial  hemorrhages;  congested 
kidneys;  congested,  soft,  friable  liver.  Thymus:  Two  (possibly  three)  imperfectly 
differentiated  lobes  with  a  prolongation  extending  through  critical  space  to  1.9  cm. 
above  superior  sternal  border;  the  flattened  inferior  aspect  was  just  over  cardiac  base 
upon  which,  when  the  auricles  were  distended,  it  no  doubt  rested;  left  lobe  extended  to 
near  middle  of  left  ventricle.     Weight  of  thymus  S.  1 1  grams.     No  gross  lesion.     (Coplin.) 

Fig.  45. — -Conglomerate  thoracic  thymus.  Female,  aged  twenty-four  hours.  Low 
attachment  and  partial  separation  of  placenta;  Cesarean  section.  Weight  of  infant  6| 
pounds.  At  birth  infant  cried  naturally,  did  well  for  twenty-four  hours,  died  in  spasm 
with  dyspnea.  Postmortem:  Aside  from  enlarged  thymus  and  changes  referable 
thereto,  nothing  abnormal  found.  Thymus  greatly  enlarged,  intensely  edematous, 
bulges  in  front  and  above  heart.  Body  opened  and  fixed  in  formalin;  thymus  dissected 
from  bed.  Weight  of  thymus  45  grams.  Histologically,  richly  cellular  thymic  tissue, 
intensely  edematotis.  Precava  and  trachea  manifestly  compressed;  trachea  collapsed. 
Irregular  areas  of  pulmonary  aeration;  all  anterior  margins  of  both  lungs  airless;  bases 
imperfectly  expanded,  many  lobules  atelectatic.      (Coplin.) 


504  DISEASES  OF   THE  DUCTLESS  GLANDS 

other  organs  of  the  body,  it  has  been  proven  that  lymphocytes  and 
eosinophiles  are  found  in  the  lymphoid  tissue  of  this  gland. 

Percussion. — The  outline  of  the  thymus  may  be  elicited  by  light 
percussion  over  the  upper  part  of  the  sternum  in  young  children, 
but  th\Tnic  dulness  disappears  after  the  second  year,  after  which  it  is 
pathological.  The  area  of  dulness  produced  by  the  thymus  in  children 
is  continuous  with  cardiac  dulness,  and  should  not  extend  more  than 
I  inch  (1  cm.)  beyond  the  margin  of  the  sternum  on  either  side. 

ATROPHY  OF  THYMUS. 

The  thymus  gland  is  very  susceptible  to  changes  in  the  general  state 
of  nutrition  of  the  body,  and  is  found  to  be  very  sm.all  in  cases  of 
malnutrition.  Infants  in  whom  the  thymus  was  so  small  as  to  be 
considered  absent,  and  in  whom  the  gland  did  not  weigh  over  30  grains, 
have  been  fatal  cases  of  marasmiLS  due  to  improper  feeding,  imperfect 
assimilation,  congenital  lues,  rachitis,  and  chronic  tuberculosis.  If 
the  case  be  one  of  chronic  toxemia  the  lymphoid  tissue  is  practically 
altogether  replaced  by  fibrous  tissue,  while  in  children  dying  of 
starvation  there  is  simply  an  atrophy  of  all  the  tissue  elements  with 
marked  reduction  in  weight. 

ENLARGEMENT  OF  THE  THYMUS. 

Acute  enlargement  of  a  normal-sized  thymus  gland  may  occur  from 
congestion  due  to  cardiac  disease  or  after  goitre  operations,  or  as  a 
result  of  h^^eremia  or  edema.  This  enlargement  is  occasionally 
sufficient  to  cause  death  from  pressure  on  the  underlying  structure. 
True  hyperplasia  of  the  thymus  has  been  observed  in  cases  of  congenital 
lues,  rachitis,  anemia,  Hodgkin's  disease,  chlorosis,  leukemia,  Addison's 
disease,  and  exophthalmic  goitre.  The  theory  has  been  advanced  that 
enlargement  of  the  thymus  is  a  secondary  compensation  measure  oc- 
curring in  infections,  auto-intoxications  or  distiu-bances  of  m.etabolism 
in  which  there  is  lymphoid  exhaustion.  Enlargement  of  the  thymus 
is  a  part  of  that  rare  condition  known  as  status  h-mphaticus,  in  which 
there  is  a  general  hypertrophy  of  the  whole  lymphatic  system. 

Pathology. — Postmortem  findings  in  a  few  cases  have  shown  merely 
congestion  or  edema  to  have  been  the  cause  of  fatal  enlargement  of  the 
thymus.  In  the  majority  of  cases  there  is  a  true  hyperplasia  of  the 
organ,  particularly  of  the  lymphoid  tissue.  Although  there  is  much 
discussion  over  the  weight  of  the  normal-sized  thymus,  a  thjTnus  over 
I  ounce  (15  gm.)  may  be  considered  as  enlarged.  Of  the  dimensions, 
increased  thickness  is  of  greatest  importance,  since  it  results  in  pressure 
on  the  underlying  structiu'es,  particularly  the  trachea  which  has  been 
found  to  be  flattened,  and  even  stenosed  to  a  considerable  degree. 
Pressure  on  the  great  vessels  may  cause  h\'pertrophy  and  dilatation 
of  the  heart.  Thrombosis  of  the  jugular  vein  has  been  found  at 
autopsy. 


ENLARGEMENT  OF  THE  THYMUS 


505 


Symptoms. — Enlarged  thymus  has  been  observed  after  death  which 
caused  no  symptoms  during  life,  but,  as  a  rule,  there  is  evidence  of 
respiratory  difficulty.  This  interference  with  respiration  may  vary 
from  mild  stridor  to  severe  dyspnea  which  terminates  fatally.  Thymic 
stridor  is  believed  to  be  due  to  compression  of  the  trachea  and  is 
usually  noticeable  at  birth,  although  it  may  not  develop  until  some 
time  after.  It  is  chiefly  inspiratory,  but  expiration  is  also  impeded. 
Attacks  of  thvmic  stridor  ma\'  be  induced  during  one  of  the  acute 


Fig.  46. — An  infant  with  an  enlarged  conglomerate  thoracic  thymus  m  situ.  A 
thyroid,  slightly  below  normal  position.  B,  lobes  of  greatly  enlarged  thymus.  Incom- 
plete separation  is  into  lobes,  upper,  right  and  left.  The  upper  is  partly  divided  by 
an  incompletely  formed  vertical  depression.  The  fissures  separating  the  lobes  are  no- 
where complete.  Near  the  left  inferior  anterior  margin  of  the  right  lobe  is  a  small 
partly  detached  mass  of  thymic  tissue  that  might  be  called  an  accessory  lobe.  C,  heart 
covered  by  intact  pericardium;  auricles  concealed  and  compressed  by  enlarged  thymus 
which  extends  a  little  lower  on  the  right  than  on  the  left  side,  thereby  conforming  to 
the  base  of  the  ventricles.     D,  summit  of  liver.      (Case  of  Dr.  E.  P.  Davis.) 


infectious  diseases,  or  may  be  precipitated  by  a  fit  of  crying  or  scream- 
ing in  which  the  head  is  thrown  backward.  These  acute  attacks,  which 
may  subside  entirely,  are  probably  due  to  congestion  of  an  already 
enlarged  gland.  In  other  cases  thymic  stridor  is  constantly  present 
and  there  is  an  audible  respiratory  sound,  both  on  inspiration  and 
expiration,  the  voice  remaining  clear.  The  intensity  of  this  sound  is 
increased  during  crying  or  coughing,  and  is  diminished  during  sleep. 
Aside  from  the  presence  of  this  stridor  the  child  may  be  practically 


506 


DISEASES  OF  THE  DUCTLESS  GLANDS 


well.  The  child  subject  to  thymic  stridor  may  suffer  from  acute 
exacerbations  in  which  the  difficulty  of  respiration  is  markedly  in- 
creased, and  these  attacks  are  known  as  thymic  asthma.  At  such  a 
time  the  child  appears  to  be  suffocating,  the  head  is  thrown  back,  and 
inspiration  is  accompanied  by  retraction  of  the  intercostal  spaces 
and  the  suprasternal  notch.  The  face  wears  an  anxious  expression 
and  becomes  cyanotic  and  then  pale.  The  extremities  are  rigid  and 
the  hands  clenched.  The  pupils  dilate,  the  heart  sounds  become  weak, 
the  pulse  is  lost  at  the  wrist,  and  the  child  may  die.  Recovery  from  the 
attack  may  be  complete  with  disappearance  of  all  symptoms,  or  the 


Fig.  47. — An  infant  with  an  enlarged  conglomerate  thoracic  thymus,  removed 
(shown  just  over  right  shoulder  of  infant),  disclosing  cavity  occupied.  A,  compressed 
cava.  B,  heart,  the  flattening  of  which  is  well  shown.  C,  summit  of  liver.  (Case  of 
Dr.  E.  P.  Davis.) 


stridor  may  persist.  As  a  rule,  repeated  attacks  occur,  growing  pro- 
gressively worse  until  death.  Cases  of  thymic  asthma  occur  in  which 
there  has  been  no  previous  thymic  stridor,  and  thymic  death  is  not 
always  preceded  by  thymic  asthma.  The  term,  thymic  death,  is 
applied  particularly  to  those  cases  of  sudden  death  attributed  to 
enlargement  of  the  thymus  in  which  there  has  been  no  previous  stridor 
or  asthma. 

The  question  as  to  whether  or  not  the  enlargement  of  the  gland 
itself  is  the  essential  pathological  basis  for  thymic  death  is  still  in 
dispute,  but  the  preponderance  of  opinion  seems  to  justify  this  con- 


STATUS  LYMPHATICUS  507 

elusion.  The  ir).anner  in  whieh  death  is  caused  by  enlargement  of  the 
thymus  has  not  been  proven  to  the  satisfaction  of  all,  but  most  authori- 
ties agree  that  the  pressure  exerted  by  the  enlarged  gland  causes 
tracheal  stenosis  and  secondary  laryngeal  spasm.  In  some  cases 
which  have  presented  no  clinical  evidence  of  stenosis  of  the  trachea 
or  spasm  of  the  larynx,  death  is  presumed  to  have  resulted  from  cardiac 
paralysis,  since  there  is  also  pressure  upon  the  heart,  great  vessels, 
and  vagi  and  recurrent  nerves.  Pressure  upon  the  great  vessels  is 
held  responsible  for  the  general  edema  usually  present  in  these  cases, 
and  pulmonary  edema  which  frequently  precedes  death  m.ay  be  due  to 
pressure  on  the  pulmonary  arteries  and  veins.  Death  from  enlarged 
thymus  is  sudden,  and  a  previously  healthy  child  may  be  found  dead 
in  bed.  Frequently  death  follows  some  trivial  accident  or  occurrence, 
such  as  fright,  or  a  fall  into  water,  a  slight  burn,  the  prick  of  a  hypo- 
dermic needle,  or  the  inhalation  of  a  few  drops  of  an  anesthetic. 
Trivial  operations,  such  as  the  extraction  of  a  tooth  or  removal  of  the 
tonsils  and  adenoids,  have  been  fatal.  Thymic  death  may  occur 
during  an  acute  infection,  and  is  particularly  frequent  in  diphtheria. 

STATUS  LYMPHATICUS. 

Status  lymphaticus  is  a  rare  condition  in  which  there  is  found  an 
enlarged  thymus  and  general  hypertrophy  of  the  lymphatic  system. 
The  tonsils  and  adenoids  are  enlarged,  and  there  is  a  hyperplasia  of 
both  superficial  and  deep  lymph  nodes.  There  is  a  tendency  to  hyper- 
plasia of  the  vascular  system,  seen  especially  in  the  aorta.  From  a 
clinical  standpoint  there  is  a  lowered  vitality,  and  an  unstable  equi- 
librium of  vital  forces  which  results  in  sudden  death  of  the  individual 
from  cardiac  and  respiratory  failure,  brought  on  by  trivial  incidents. 

Symptoms. — The  child  may  be  apparently  well,  but  looks  anemic, 
and  frequently  shows  signs  of  rachitis.  It  is  subject  to  frequent 
attacks  of  tonsillitis  and  catarrhal  conditions  of  the  nose  and  throat. 
Gastro-intestinal  disturbances  are  common.  Cyanosis,  dizziness,  and 
syncope  indicate  an  unstable  circulation.  A  prominence  of  the  upper 
part  of  the  sternum  and  the  suprasternal  notch  may  be  visible  on 
inspection.  The  upper  part  of  the  gland  m.ay  be  palpable  at  the  root 
of  the  neck,  and  the  superficial  lymph  glands  and  spleen  are  found  to 
be  enlarged  on  palpation.  Thymic  dulness  is  increased  as  is  shown 
by  a  wider  area  of  impaired  resonance  on  both  sides  of  the  upper  part 
of  the  sternum.  The  stridor  is  frequently  audible  some  distance  from 
the  patient,  and  is  always  heard  distinctly  all  over  the  chest. 

Diagnosis. — The  diagnosis  of  enlarged  thymus  is  based  upon  the 
occurrence  of  chronic  stridor,  usually  congenital,  which  at  times 
becomes  severe,  resembling  asthm.a,  and  may  require  intubation  or 
tracheotomy  for  the  relief  of  dyspnea.  Careful  examination  of  the 
throat  should  be  made  to  exclude  adenoids  or  malformations  or 
obstruction  of  the  larynx  as  a  cause  of  the  stridor.  Enlarged  bronchial 
glands  may  produce  stridor  by  compression,  but  the  enlargement 


508  DISEASES  OF  THE  DUCTLESS  GLANDS 

usually  follows  pertussis  or  bronchopneumonia,  while  thymic  stridor 
is  apt  to  be  congenital.  The  a--ray  is  probably  the  most  valuable  aid 
in  diagnosis  of  enlarged  thymus,  although  variation  in  size,  within 
reasonable  limits,  may  be  expected  under  normal  conditions. 

Prognosis. — The  prognosis  of  thymic  enlargement  is  unfavorable. 
Recovery  is  quite  common  in  those  cases  with  mild  stridor,  but  when 
more  severe  symptoms  develop,  a  fatal  outcome  is  to  be  expected. 
Intubation  or  operations  on  the  thymus  are  often  successful  in  relief 
of  symptoms,  or  as  cm-ative  measures,  but  are  very  dangerous  pro- 
cedm-es,  since  death  frequently  occurs  during  the  administration  of  an 
anesthetic  or  on  the  operating  table.  Intercurrent  infections  are  often 
fatal  in  a  child  with  an  enlarged  thymus. 

Treatment. — The  child  with  an  enlarged  thymus  should  live  as  quiet 
a  life  as  possible,  and  be  carefully  guarded  from  all  excitem.ent.  The 
general  health  must  be  improved  by  careful  hygiene,  outdoor  life, 
and  well-regulated  diet.  Bathing  should  be  carried  out  most  carefully 
and  always  in  lukewarm  water,  as  either  extreme  of  temperature  may  be 
fatal.  Acute  infections  of  the  upper  respiratory  tract  are  especially 
liable  to  precipitate  an  attack  of  thymic  asthma,  and  should  be  care- 
fully avoided.  During  an  acute  attack  of  stridor  or  asthma  hot  or  cold 
applications  may  be  made  to  the  neck  or  sternum.  Cardiac  stimulants 
with  oxygen  may  be  necessary  to  prevent  suffocation.  If  dyspnea 
is  severe,  intubation  or  tracheotomy  may  be  necessary.  The  parents 
should  be  told  of  the  possibility  of  sudden  death  before  anesthetization, 
which  should  be  proceeded  with  most  cautiously.  Tracheotomy  may 
be  done  under  local  anesthesia,  and  chloroform  given  through  the 
tracheal  cannula  is  preferred  for  thymectomy.  Intubation  m.ay  termin- 
ate a  severe  attack  of  thymic  asthma,  but  if  there  be  a  stenosis  of  the 
trachea,  the  withdrawal  of  the  tube  causes  another  attack.  The 
Roentgen  ray  brings  about  a  decrease  in  size  of  the  thymus,  lymph 
nodes,  and  spleen  when  applied  to  the  thymus  in  status  lymphaticus, 
and  the  results  are  so  satisfactory  that  this  plan  of  treatm.ent  should 
always  be  tried.  In  children  Roentgen  irradiation  is  preferred  to 
thymectomy  because  of  the  effect  of  removal  of  the  thym.us  on  the 
bones  and  sexual  organs.  For  this  reason  partial  thymectomy  is  the 
usual  operation,  or  the  organ  may  be  stitched  to  the  under  surf-ace 
of  the  sternum. 


DISEASES   OF   THE   THYROID   GLAND. 

GOITRE. 

Acquired  goitre  occurs  most  frequently  in  children  at  or  before 
puberty,  while  congenital  goitre  is  very  rare  and  is  only  seen  in 
goitrous  districts  where  the  parents  are  also  goitrous.     The  infectious 


GOITRE  509 

diseases  are  occasionally  followed  by  goitre.  Exophthalmic  goitre  is 
rare  in  childhood,  but  may  occur  in  the  first  year. 

Exophthalmic  Goitre  (Graves's  Disease). — This  disease,  which  was 
first  described  by  Graves  in  1835,  is  characterized  by  enlargement 
of  the  thyroid  gland,  tachycardia,  exophthalmos,  and  muscular  tremors. 

Etiology. — Emotional  shocks,  such  as  fright,  grief,  worry,  are  said 
to  be  important  factors  in  the  production  of  Graves's  disease.  During 
childhood  it  is  most  apt  to  occur  in  neurotic  girls,  at  or  about  puberty. 
Infection  can  only  be  indirectly  associated  with  exophthalmic  goitre. 
The  children  of  epileptic  and  alcoholic  parents  are  said  to  be  pre- 
disposed to  this  disease.  It  is  more  than  twice  as  frequent  in  girls  as 
in  boys,  but  care  must  be  taken  not  to  confuse  the  hyperemic  goitre 
which  occurs  in  young  girls  with  exophthalmic  goitre.  The  hyperemic 
goitre  is  not  accompanied  by  exophthalmos  or  tremors,  and  the  con- 
dition disappears  with  m.enstruation. 

Symptoms. — The  symptoms  of  exophthalmic  goitre  in  the  child 
are  practically  the  sam.e  as  in  the  adult.  There  is  enlargement  of  the 
thyroid  gland,  tachycardia,  exophthalm.os,  and  muscular  tremors. 
The  symptoms  m.ay  resemble  chorea.  The  child  is  irritable,  easily 
excited,  and  becom.es  depressed  if  left  alone.  There  may  be  nausea 
and  vomiting  at  the  sight  of  food.  In  early  childhood  there  is  usually 
profuse  diarrhea.  The  general  health  of  the  child  is  poor,  sleep  is 
disturbed,  and  there  may  be  attacks  several  times  a  day  in  which  there 
is  a  breaking  out  into  cold  perspiration.  The  skin  may  be  pigm.ented. 
The  eyes  are  staring  and  may  bulge  out  of  the  orbital  cavity  so  that 
there  may  be  hesitation  in  the  descent  of  the  upper  lid  when  the  eyes 
are  turned  down.  The  enlargement  of  the  thyroid  is  usually  bilateral. 
There  is  a  systolic  murmur  at  the  base  of  the  heart,  the  blood-pressure 
is  increased,  and  hem.orrhages  m.ay  arise  from  the  nose,  stomach,  or 
intestines. 

Prognosis. — Graves's  disease  is  rarely  fatal  in  children  but  tends  to 
run  a  chronic  course  with  remissions  of  symptoms.  The  younger  the 
child,  the  better  the  prognosis,  as  a  rule. 

Treatment. — The  patient  should  be  put  to  bed  and  kept  there  until 
the  active  symptoms  subside.  The  diet  should  be  nutritious,  but  light, 
in  order  to  avoid  gastro-intestinal  disturbances.  The  tachycardia 
may  be  so  severe  as  to  demand  attention,  and  for  this  the  child  may  be 
given  spartein  sulphate,  strophanthus  or  digitalis.  Cold  applications 
to  the  heart  are  also  beneficial.  Belladonna  com.bined  with  sodium 
iodide  is  beneficial  in  some  cases.  In  conjunction  with  this  treatment, 
the  x-rays,  galvanic  current,  and  injection  of  serum  are  som.etim.es 
used.  Thyroidectin,  a  product  from  thyroidectomized  sheep,  has 
proven  of  distinct  value  in  many  cases  and  should  be  administered. 
The  use  of  thyroid  extract  or  the  gland  substance  is  contraindicated. 
Adrenalin  extract  and  thymus  gland  have  been  used.  When  medical 
treatment  fails,  the  case  should  be  treated  surgically,  a  partial  thy- 
roidectomy being  the  usual  operative  procedure. 


510  DISEASES  OF  THE  DUCTLESS  GLANDS 

CRETINISM. 

Cretinism  is  a  form  of  idioc}'^  associated  with  myxedematous  cachexia 
and  defective  growth  of  the  bony  skeleton,  and  is  due  to  deficient 
secretion  of  the  thyroid  gland.  There  are  two  forms,  the  sporadic  and 
endemic,  but  the  latter  type  does  not  occur  in  the  United  States. 

Etiology. — The  endemic  form  of  cretinism  is  seen  in  many  of  the 
geographical  locations  of  endemic  goitre.  It  is  common  in  the  goitrous 
districts  of  Europe,  and  particularly  in  Styria,  the  Tyrol,  Savoy, 
Piedmont,  and  in  Switzerland,  but  does  not  exist  in  those  areas  of 
North  America  where  goitre  is  of  frequent  occurrence.  Cretins  in  goitre 
districts  have  goitrous  mothers,  or  both  parents  may  be  mild  cretins, 
but  cretins,  as  a  rule,  cannot  conceive  or  bear  a  living  child.  The 
thyroid  gland  usually  presents  a  goitre,  and  shows  extensive  degenera- 
tion in  this  form  of  cretinism,  but  the  symptoms  are  practically  the 
same  as  in  the  sporadic  type.  Sporadic  cretinism  is  related  to  endemic 
cretinism,  but  the  etiology  and  pathology  differ.  The  parents  of 
sporadic  cretins  are  not  goitrous,  as  a  rule,  but  tuberculosis,  alcoholism, 
and  consanguinity  in  the  parents  are  said  to  have  a  predisposing 
influence.  Psychical  disturbances  in  the  mother  during  pregnancy, 
such  as  grief,  worry,  and  fright  have  been  noted  in  connection  with 
cretinism.  Thyroiditis,  arising  from  trauma  or  during  measles, 
enteritis,  or  typhoid  fever  may  give  rise  to  cretinism.  It  is  rare  in 
tropical  climates,  and  extremely  unusual  in  the  negro.  Male  cretins 
are  more  common  than  females. 

Pathology. — The  most  important  changes  in  the  body  of  the  cretin 
are  related  to  the  thyroid  gland.  The  gland  may  be  congenitally 
absent.  In  other  cases  it  is  goitrous,  and  in  most  cases  it  is  atrophied. 
It  may  be  so  small  as  to  be  overlooked  after  careful  search,  and 
considered  absent.  The  bony  skeleton  shows  arrested  and  retarded 
development.  The  bones  of  the  skull  are  thickened,  the  sutures  remain 
open,  and  the  fontanelles  do  not  close  until  late.  The  base  of  the  sk,ull 
may  be  altered  in  shape,  and  the  posterior  clinoid  processes  are  higher 
than  the  anterior.  The  foramina  are  narrowed.  The  bones  of  the 
extremities  and  the  ribs  may  be  altered  in  shape.  The  pelvis  is  narrow. 
Bony  changes  vary  in  degree  according  to  the  age  at  which  the  lack  of 
th;^Toid  secretion  was  felt.  Adipose  tissue  is  very  abundant  in  the 
omentum,  and  also  beneath  the  skin  which  is  thick,  with  scanty 
development  of  hair  and  sweat  glands.  The  brain  shows  no  gross 
abnormality,  but  the  pituitary  is  occasionally  found  to  be  atrophied  or 
hypertrophied. 

Symptoms. — Evidences  of  cretinism  are  rarely  noticed  by  the  parents 
until  after  the  first  year.  In  those  cases  observed  before  the  first  year 
the  infant  is  dull  and  passive,  mentally  inactive,  and  takes  little  or  no 
interest  in  its  surroundings,  or  as  to  how  it  is  manipulated.  It  is 
usually  of  normal  length  and  weight  at  birth,  but  fails  to  gain  in  height 
or  weight.  A  child  of  eight  years  will  simulate  one  of  three,  and  full- 
grown  cretins  are  never  over  three  to<,five  feet  tall.    The  skin  is  thick. 


CRETINISM 


511 


coarse,  and  dry,  but  does  not  pit  on  pressure.  The  hair  is  dry  and 
coarse  and  grows  poorly.  The  fontanelles  remain  open  late,  but  there 
are  no  signs  of  rachitis.  The  teeth  may  not  appear,  or  if  they  do 
are  late  and  very  imperfect.  The  eyelids  are  wide  apart.  The 
nose  is  flattened,  with  the  nostrils  dilated,  and  the  bridge  sunken. 
The  ears  are  large,  and  have  a  waxy  appearance.  The  lips  are  thick, 
and  the  tongue  which  is  thickened  and  broad,  protrudes  from  the 
mouth.  The  neck  is  short  and  thick,  and  the  head  appears  to  be  placed 
directly  on  the  chest  which  is  short  and  hollow.  The  abdomen  is 
usually  large,  protuberant,  and  there  is  invariably  an  umbilical  hernia. 
The  arms  and  legs  are  slrort  and  stubby.    The  hands  are  spade-like. 


Fig.  48. — Cretinism. 


and  the  fingers  are  blunt.  The  genitals  are  large,  and  the  skin  of  the 
scrotum  is  thick.  Mental  dulness  may  be  noticed  as  early  as  the  sixth 
month.  The  child  has  a  vacant  stare,  a  meaningless  smile,  and  does 
not  play.  Deafness  caused  by  adenoids  or  middle-ear  disease,  which 
is  common  in  cretins,  adds  to  the  deficient  mental  state.  Cretins 
may  be  trained  just  as  animals  are,  and  may  even  learn  easy  sen- 
tences, but  further  mental  development  is  impossible.  Both  mental 
and  physical  exertions  are  difficult.  The  habits  are  uncleanly,  and 
the  disposition  is  usually  pleasant,  but  may  be  vicious.  The  tem- 
perature is  subnormal.  The  appetite  is  good  but  there  is  apt  to  be  a 
dislike  for  meat.     Constipation  is  usually  met  w^th,  is  obstinate,  and 


512 


DISEASES  OF  THE  DUCTLESS  GLANDS 


may  persist  for  a  long  time.  Blood  examination  reveals  an  anemia 
with  marked  diminution  in  red  cells  and  hemoglobin.  The  thyroid 
gland  is  not  palpable.  The  arrest  in  mental  and  physical  development 
varies  according  to  the  age  at  which  the  deficiency  of  thyroid  secretion 
became  effective. 

Diagnosis. — The  diagnosis  of  a  typical  case,  well  advanced,  is  easily 
made,  but  early  diagnosis,  which  is  so  extremely  important,  may  be 
very  difficult  in  infancy.  The  coarse,  dry  skin,  short  stubby  extremities, 
subnormal  temperature,  and  slow  mental  responses  form  a  combina- 
tion which  points  strongly  to  cretinism.  It  must  be  differentiated 
from  rachitis,  Mongolian  idiocy,  achondroplasia,  and  dwarfism. 


Fig.  49. — A  cretin,  eighteen  years  old. 


Rickets. — The  mentality  in  rickets  is  normal,  and  the  characteristic 
bony  changes  are  easily  demonstrated  by  the  skiagraph. 

Dwarfism. — Even  if  associated  with  idioc}',  dwarfism  may  be 
differentiated  by  the  absence  of  the  facial  expression  of  the  cretin 
and  the  skin  changes.  The  body  of  the  dwarf  shows  symmetry,  which 
the  cretin  lacks. 

Mongolian  Idiocy. — Mongolian  idiots  present  the  characteristic 
slanting  eyes,  but  lack  the  peculiar  faces  of  the  cretin.  The  body 
is  more  symmetrical,  and  instead  of  the  apathy  of  the  cretin  undue 
restlessness  is  the  rule. 


CRETINISM 


513 


Achrondroplasla. — This  disease  may  be  differentiated  from  cretinism 
by  the  fairly  well-developed  intellect,  and  the  more  marked  shortness 
of  the  extremities.  The  size  of  the  thyroid  gland  may  be  of  service  in 
clearing  up  a  puzzling  case,  and  a  trial  administration  of  thyroid 
extract  will  show  definitely  whether  cretinism  be  present  or  not. 

Prognosis. — The  prognosis  depends  largely  upon  the  stage  of  the 
disease  at  which  treatment  was  instituted.  The  earlier  it  is  given,  the 
greater  the  improvement,  but  if  the  condition  is  neglected  and  allowed 
to  continue  too  long  the  case  may  go  beyond  medical  aid  and  fail  to 
show  even  temporary  improvement  under  treatment.  When  treat- 
ment is  carried  out  thoroughly  from  an  early  stage  of  the  disease,  the 
improvement  is  miraculous.  The  child 
grows  taller,  gaining  several  inches  each 
year.  It  loses  its  dull,  apathetic  appearance, 
and  the  mind  becomes  alert  and  receptive. 
Cretins  rarely  live  over  thirty  years,  although 
exceptional  cases,  attaining  the  age  of  fifty 
and  sixty  years,  have  been  reported.  Death 
is  usually  due  to  an  intercurrent  infection,  to 
which  they  are  very  susceptible. 

Treatment. — The  cretin  must  be  treated 
for  years  if  permanent  results  are  to  be 
obtained.  The  fact  that  the  most  beneficial 
results  of  treatment  are  noticed  where  it  is 
instituted  early  in  life,  has  already  been 
emphasized.  After  treatment  is  once  begun, 
a  neglect  of  it  causes  a  relapse  and  tendency 
toward  the  original  condition.  The  ad- 
ministration of  the  desiccated  extract  of  the 
thyroids  of  sheep  is  the  accepted  treatment 
for  cretinism.  The  dose  should  commence 
with  \  grain  t.  i.  d.  for  an  infant,  and  pro- 
portionately larger  doses  for  children.  The 
amount  of  thyroid  taken  daily  should  be  in- 
creased until  the  maximum  effect  is  obtained, 
and  then  kept  at  that  level  until  the  de- 
sired improvement  has  taken,  place.  Recession  of  the  tongue,  loss  of 
adipose  tisue,  change  in  the  facial  expression,  and  mental  changes  are 
the  first  signs  of  improvement.  The  skin  becomes  moist  with  restora- 
tion of  activity  in  the  sweat  glands,  the  hair  grows  more  abundantly, 
and  is  fine  and  glossy.  The  body  becomes  shapely,  and  there  is  a  rapid 
increase  in  height.  The  mental  improvement  is  even  greater  than  the 
physical  change.  These  results  are  usually  obtained  without  increasing 
the  dose  over  15  to  30  grains  daily,  according  to  age.  Mtev  definite 
improvement  is  noticed  the  dose  may  be  gradually  cut  down,  and  even 
stopped  at  intervals,  until  the  actual  amount  of  thyroid  required  by 
the  patient  is  ascertained.  Grafting  the  thyroid  gland  has  not  met 
with  definite  success,  and  the  old  method  of  feeding  the  fresh  gland, 
33 


Fig.  50. — A  cretin,  twelve 
years  old. 


514  DISEASES  OF  THE  DUCTLESS  GLANDS 

either  cooked  or  uncooked,  has  been  discarded.  Overdoses  of  the 
thyroid  extract  may  be  quite  serious,  and  too  large  doses  cause  head- 
ache, faintness,  rapid  pulse,  nausea,  and  fever.  Exaggerated  pulse 
rate  is  an  indication  to  cut  down  the  dosage.  In  addition  to  the 
administration  of  thyroid  extract,  the  child  should  have  the  benefit 
of  the  best  hygienic  measures.  The  diet  should  be  carefully  watched, 
and  the  protein  intake  increased.  Fresh  air  is  essential,  and  massage 
and  exercise  are  of  distinct  value. 


DISEASES   OF   THE   ADRENAL   GLANDS. 

The  adrenals  rarely  become  diseased  before  the  tenth  year,  but 
during  early  childhood  may  be  the  seat  of  hemorrhages  or  tumors. 
Hemorrhages  into  the  adrenals  may  be  capillary  or  punctate.  They 
occur  in  the  newborn,  during  the  course  of  gastro-enteric  infection, 
chronic  cardiac  or  pulmonary  disease,  and  in  septicemia  and  pyemia. 
Some  writers  attempt  to  classify  the  symptoms  into  three  groups: 
asthenic,  nervous,  and  peritoneal.  There  is  usually  associated  with 
hemorrhage  of  the  adrenals  a  severe  acute  illness  and  purpura.  The 
onset  is  sudden,  with  fever,  violent  pain  in  the  hypochondrium, 
convulsions,  vomiting,  diarrhea,  tympanites,  collapse  and  death  in 
forty-eight  hours.  The  symptoms,  together  with  the  purpura,  simulate 
a  fulminating  type  of  one  of  the  exanthemata,  and  unvaccinated  cases 
are  not  infrequently  mistaken  for  smallpox.  The  pathology  is  unknown, 
and  the  treatment  ineffectual,  because  of  the  rapid  progress  and 
peculiar  nature  of  the  affection. 

Tumors  of  the  adrenals,  arising  during  childhood,  may  cause  marked 
disturbances  in  development  with  regard  to  growth,  and  sexual  develop- 
ment particularly.  In  some  cases  the  symptoms  are  thought  to  be  due 
to  hypersecretion,  and  in  other  cases  to  toxic  products  from  a  breaking- 
down  process  in  the  tumors.  It  occurs  much  more  frequently  in  girls 
than  in  boys,  and  if  the  girl  be  very  young  she  tends  to  acquire  the 
male  sex  characteristics.  The  reverse  is  not  true  in  boys,  but  their 
development  is  also  precocious.  There  is  a  marked  tendency  to  take 
on  fat,  and  an  excessive  growth  of  body  hair.  The  outlook  in  these 
cases  is  unfavorable,  for  diagnosis  is  difficult,  the  growth  rapid,  and 
metastasis  early  and  frequent. 


ADDISON'S  DISEASE. 

Addison's  disease  is  rare  in  children,  and  when  it  does  occur  usually 
comes  on  after  the  tenth  year.  It  is  characterized  by  pigmentation, 
muscular  and  vascular  weakness,  and  nervous  and  gastro-intestinal 
disturbances. 


ADDISON'S  DISEASE  515 

Etiology. — The  exciting  cause  and  predisposing  factors  of  Addison's 
disease  are  unknown. 

Pathology. — In  the  majority  of  cases  there  is  a  lesion  of  the  adrenals 
which  shows  caseation  and  calcification.  Tuberculosis  also  may  be 
demonstrated  in  other  parts  of  the  body.  The  tubercle  bacilli  may 
be  present  in  the  adrenals  at  death.  Some  few  cases  are  not  tuberculous 
and  the  gland  may  show  simple  atrophy,  resulting  from  a  chronic 
interstitial  inflammation.  Sarcoma,  cancer,  and  hypernephroma  of  the 
adrenals  have  also  been  found  associated  with  Addison's  disease. 

Symptoms. — The  skin  is  pigmented  and  becomes  a  deep  yellow  or 
bronze;  the  discoloration  beginning  at  the  nipples,  axillary  regions, 
hands  and  face.  The  mucous  membranes  of  the  mouth  and  vagina 
are  also  pigmented.  White  areas  of  skin  may  be  observed  scattered 
over  the  body.  Pigmentation  of  the  mucous  membranes  is  said  to  be 
pathognomonic  of  Addison's  disease.  The  child  very  gradually  becomes 
weak  and  em.aciated  and  listless.  This  weakness  progresses  steadily 
to  exhaustion,  and.  the  emaciation  grows  worse,  wdth  a  rapidly  develop- 
ing secondary  anemia.  There  are  vomiting,  diarrhea,  and  other  gastro- 
intestinal disturbances.  Nervous  symptoms  are  marked,  and  con- 
vulsions m.ay  occur.  The  heart  is  weak,  and  dyspnea  and  palpitation 
follow  the  slightest  exertion.  There  may  be  abdominal  pain,  with 
rigidity  of  the  walls  of  the  abdom.en,  suggesting  peritonitis. 

Diagnosis. — Although  Addison's  disease  is  rarely  seen,  the  diagnosis 
may  be  made  easily  if  there  is  pigmentation  with  gradual  asthenia, 
uncontrollable  diarrhea,  vomiting,  and  abdominal  pain.  The  pig- 
mentation must  be  differentiated  from  that  caused  by  m.etallic  poisons, 
such  as  silver,  lead,  and  arsenic.  Other  symptoms  of  Addison's 
disease  may  suggest  a  prim.ary  anemia,  but  this  m.ay  be  excluded  by 
careful  study  of  the  blood.  Tuberculosis  of  the  peritoneum.,  with 
melanoderm.ic  and  abdominal  crisis  may  resem.ble  Addison's  disease, 
but  there  is  no  pigm.entation  of  the  mucous  membranes  in  tuberculous 
peritonitis. 

Prognosis. — The  course  of  the  disease  is  m.uch  m.ore  rapid,  and 
death  comes  on  sooner  in  children  than  in  adults.  Practically  every 
case  is  fatal,  and  doubt  exists  as  to  the  true  nature  of  the  disease  in 
those  cases  with  recoveries  reported,  although  recovery  is  possible. 
If  there  is  uncom.plicated  tuberculosis  of  the  gland,  the  disease  runs  a 
slow  course  and  ro.ay  last  years,  but  cases  due  to  atrophy  of  the  adrenals 
are  rapidly  fatal.  Death  m.ay  come  on  gradually  from,  exhaustion, 
or  suddenly  with  diarrhea,  vomiting,  fever,  syncope,  toxic  symptoms, 
and  paralysis  of  the  cardiac  muscles. 

Treatment. — The  treatment  of  Addison's  disease  is  largely  symptom- 
atic. The  child  should  have  plenty  of  rest,  a  light  nutritious  diet, 
and  be  kept  warm  at  all  times.  Tonics  containing  arsenic  or  strychnine 
may  be  given.  Hem.atinics  and  roborants  are  sometimes  used. 
Glandular  extracts  from  the  parathyroids,  pituitary,  and  suprarenals 
have  been  tried  in  these  cases  with  indifferent  success.  The  adrenal 
gland  of  the  sheep  may  be  given  raw  or  cooked ;  the  dose  varies  up  to 


516  DISEASES  OF  THE  DUCTLESS  GLANDS 

one-half  gland,  according  to  the  age  of  the  child.  The  dose  of  the 
dried  gland  in  tablet'  form  is  from  i  to  |  grain  t.  i.  d.  There  have 
been  cases  reported  where  adults  were  benefited  by  operative  treat- 
ment, and  this  may,  at  times,  be  advisable  in  the  child. 


THE   PINEAL   GLAND. 

The  pineal  body  which  lies  under  the  posterior  end  of  the  corpus 
callosum  is  occasionally  during  childhood  the  site  of  tumors  which 
cause  characteristic  changes  in  development.  The  growth  of  the 
child  is  markedly  increased  and  there  is  psychic  as  well  as  physical 
precocity.  The  sexual  organs  grow  very  rapidly  and  functionate 
early.  In  boys,  especially,  there  is  early  and  profuse  growth  of  the 
beard  and  body  hair.  The  child  is  obese,  the  voice  changes  early  and 
cachexia  gradually  develops.  As  in  tumors  of  the  pituitary  gland, 
the  progress  varies  according  to  whether  the  tumor  be  malignant  or 
benign.  In  either  case  the  prognosis  is  fatal,  and  treatment,  at  the 
best,  will  only  bring  temporary  relief  of  sym.ptom.s. 


THE   PITUITARY   GLAND. 

The  pituitary  body  is  sometimes  during  childhood  the  site  of 
both  benign  and  m.alignant  tumors,  which,  in  addition  to  the  usual 
sym.ptom.s  of  cerebral  tumor,  also  cause  precocious  developm.ent. 
There  is  a  marked  increase  in  adipose  tissue  and  a  lack  of  sexual 
developm.ent,  the  diminutive  size  of  the  organs  being  m.ade  m.ore 
striking  by  the  oversized  child.  The  penis  may  be  infantile  after  the 
age  of  puberty.  Sym.ptom.s  of  cerebral  tumor  are  usually  present,  and 
include  headache,  vertigo,  vomiting,  somnolence,  and  epilepsy,  with 
disorders  of  the  taste,  smell,  and  vision.  The  course  depends  upon  the 
character  of  the  growth,  and  is  rapid  if  there  be  malignancy,  but  m.ay 
be  very  gradual,  with  remissions,  if  the  tumor  is  benign.  The  treat- 
m.ent  is  surgical  if  the  symptoms  becom.e  severe,  but  the  ultimate 
result  is  fatal.  The  headache  is  often  severe  and  hard  to  relieve. 
Pituitary  extract  has  been  used  upon  the  basis  of  hyposecretion, 
and  thyroid  extract  is  sometimes  given  for  the  adiposity. 


CHAPTER  XVIII. 
DISEASES  OF  THE  BONES  AND  JOINTS. 

ACUTE  INFECTIOUS  OSTEOMYELITIS. 

Definition. — Acute  infectious  osteomyelitis  is  most  common  during 
childhood  and  signifies  an  acute  infectious  inflammation  of  the  bones. 

Etiology. — The  infection  is  hematogenous,  the  organisms  gaining 
access  to  the  blood  through  ulceration  of  the  mucous  membranes, 
lesions  of  the  skin,  and  intestines.  The  Staphylococcus  pyogenes 
aureus  is  the  invading  organism  in  most  cases,  but  the  Bacillus  influenzae. 
Bacillus  coli,  and  Bacillus  typhosus  have  also  been  isolated.  Strepto- 
cocci may  be  found  in  cultures  from  cases  following  scarlet  fever, 
measles,  or  pneumonia.  The  pneumococcus  has  been  isolated  in  a 
few  cases,  and  may  complicate  or  occur  independently  of  pneumonia. 
Injury  to  a  bone  predisposes  to  an  acute  osteomyelitis,  and  compound 
fractures  are  a  common  cause.  This  disease  occurs  with  equal  frequency 
in  boys  and  girls. 

Pathology. — The  infection  may  begin  as  a  periostitis  and  extend 
into  the  marrow  cavity  through  the  Haversian  canals  or  juxta-epiphy- 
seal  disks,  or  it  may  arise  in  the  marrow  cavity  and  infiltrate  the 
cancellous  bone,  giving  rise  to  necrosis  with  a  periostitis  following. 
After  the  deposition  of  the  infecting  organism  in  the  tissues,  there 
follows  hyperemia,  swelling,  and  rapid  formation  of  pus  which  may 
fill  the  medullary  cavity.  The  pus  may  infiltrate  the  epiphysis  and  the 
joint  may  become  involved,  or  it  may,  after  involving  the  periosteum, 
rupture  through  and  burrow  along  the  line  of  least  resistance  to  the 
skin. 

As  a  rule  the  infection  spreads  rapidly,  but  it  may  become  circum- 
scribed in  a  bone,  forming  a  bone  abscess.  The  long  bones  are  most 
frequently  involved,  but  acute  osteomyelitis  has  been  observed  in 
the  bones  of  the  hands,  feet,  and  skull. 

Symptoms. — The  onset  is  sudden  in  children.  There  is  high  fever, 
preceded  by  a  chill  and  accompanied  frequently  by  vomiting.  Pain 
is  acute  and  severe,  and  there  is  exquisite  tenderness  in  the  affected 
part.  This  may  be  hard  to  dem.onstrate  in  very  young  children,  but 
the  part  soon  becomes  red  and  swollen,  with  an  increase  in  the  local 
temperature.    Bacteria  may  be  found  in  the  blood  stream. 

Diagnosis. — The  diagnosis  is  not  usually  attended  with  difficulty 
and  is  made  on  the  acute  onset,  with  localized  symptoms  usually 
referable  to  one  of  the  long  bones,  and  accompanied  by  severe  con- 
stitutional disturbances. 

Prognosis. — The  prognosis  is  serious  in  very  young  children,  and  the 
mortality  is  over  50  per  cent.    This  is  caused  by  the  development  of 


518 


DISEASES  OF   THE  BONES  AND  JOINTS 


secondary  foci  of  suppuration.    In  older  children  the  outlook  is  much 
better,  and  recovery  may  be  expected  in  over  80  per  cent,  of  cases. 

Treatment. — The  treatment  of  acute  infectious  osteomyelitis  is 
surgical. 

TUBERCULOSIS  OF  BONES. 

Bone  tuberculosis  may,  as  a  part  of  miliary  tuberculosis,  give  rise 
to  an  acute  tuberculous  osteomyelitis,  but  the  chronic  form  of  bone 
tuberculosis  is  by  far  the  most  common  type.  The  bacilli  are  carried 
to  the  bone  through  the  blood  stream,  and  iRay  set  up  a  destructive 
inflammatory  process  in  any  part  of  the  bone,  but  the  infection  usually 


Fig.  51. — Tuberculosis  of  toot. 


begins  in  the  epiphysis.  The  process  shows  a  tendency  to  extend, 
and,  as  a  result,  the  neighboring  joint  and  surrounding  tissues  become 
involved,  with  the  formation  of  a  "cold  abscess.'' 

Bone  tuberculosis  is  usually  secondary  to  some  foci  in  the  body. 
The  human  type  of  tubercle  bacillus  is  practically  always  present. 
During  the  first  three  months  of  life,  tuberculosis  of  bone  is  rare.  The 
most  frequent  sites  are  the  neighborhood  of  joints  of  the  vertebrae 
and  the  long  bones,  while  the  bones  of  the  hands  and  fingers  are  very 
rarely  involved. 

Symptoms. — Pain  is  constant  in  bone  tuberculosis,  but  is  often 
indefinite  and  obscure.     It  is  rarely  present  in  the  onset,  and  when 


SYPHILIS  OF  BONES  '  519 

present  is  almost  invariably  referred  to  some  other  part.  The  sur- 
rounding tissues  are  gradually  involved,  causing  swelling  of  the  part 
and  frequently,  suppuration.  The  general  health  is  impaired,  and 
emaciation  and  cachexia  develop  in  the  later  stages. 

Diagnosis. — The  question  as  to  whether  a  bone  lesion  is  s>"philitic 
or  tuberculous  will  arise  in  a  great  many  cases.  If  tuberculous  the 
pain  is  less  severe,  suppuration  is  m.ore  frequent,  and  the  tissues 
surrounding  the  infected  bone  are  involved.  Other  foci  of  tuberculosis 
may  sometimes  be  found,  and  a  tuberculin  test  should  be  made.  The 
constitutional  symptoms  are  more  marked  in  tuberculosis  of  the  bones. 
In  acute  inflammation  the  process  is  always  rapid,  while  tuberculosis 
is  slow. 

Prognosis. — The  prognosis  is  good  if  the  case  is  treated  early  and  upon 
rational  principles  that  have  been  proven  efficacious  in  lung  tuberculosis. 

Treatment. — The  treatment  of  bone  tuberculosis  is  both  general 
and  local.  Outdoor  life  at  the  seashore  where  the  climate  is  equable 
is  ideal  for  these  children.  The  diet  should  consist  largely  of  milk, 
eggs,  oatmeal,  and  other  high  protein  cereals.  Tonics,  such  as  cod- 
liver  oil,  malt,  tincture  of  nux  vomica,  iron,  and  quinine  are  indicated 
if  they  do  not  interfere  with  digestion  and  the  appetite. 

Local  treatment  consists  in  extreme  conservation,  which  is  more 
successful  in  children  than  in  adults,  probably  because  the  after- 
treatment  is  carried  out  to  a  greater  degree.  Avoidance  and,  later, 
correction  of  deformity  are  aimed  at,  and  strict  immobilization  is 
maintained  in  the  most  favorable  position  by  means  of  carefully 
applied  plaster-of-Paris  splints. 

Abscesses  should  rarely  be  opened,  as  they  always  become  absorbed 
when  the  patient's  general  health  has  received  proper  attention. 
Injection  treatment  in  bone  tuberculosis  is  useless.  The  evacuation 
of  a  tuberculous  abscess  always  tends  toward  a  perpetual  sinus,  with 
accompanying  mixed  infection. 

SYPHILIS  OF  BONES. 

The  bone  changes  in  delayed  hereditary  syphilis  usually  come 
on  at  about  the  fifth  year.  The  long  bones  are  most  frequently 
involved,  particularly  the  tibia.  The  greatest  changes  are  seen  at  or 
near  the  epiphysis,  causing  an  irregular  broadening  of  the  epiphyseal 
line.  There  are  proliferative  changes  in  the  periosteum  from  a  chronic 
or  subacute  periostitis,  and  this  may  often  be  detected  by  running 
the  finger  down  along  the  crest  of  the  tibia.  The  epiphyseal  junction 
is  enlarged  and  swollen,  and  in  exceptional  cases  the  epiphysis  may 
become  detached.    Gummata  are  infrequent  in  bones. 

Symptoms. — Swelling  and  enlargement  of  the  epiphysis,  with 
roughening  along  the  shafts  of  the  long  bones,  is  characteristic  of 
syphilis.  Pain  is  acute  and  worse  at  night.  Suppuration  rarely  occurs 
as  a  result  of  bone  syphilis,  and  there  is  no  cachexia  or  other  marked 
constitutional  symptom. 


520 


DISEASES  OF  THE  BONES  AND  JOINTS 


Diagnosis. — Bone  syphilis  must  be  differentiated  from  tuberculosis 
of  the  bones,  and  from  rachitis.  In  addition  to  the  points  of  differen- 
tiation from  tuberculosis,  mentioned  in  the  diagnosis  of  bone  tuber- 
culosis, a  positive  Wassermann  reaction  and  the  concomitant  signs  of 
syphilis  may  be  present.  In  rachitis  the  bones  are  not  so  painful  as  in 
syphilis,  and  there  is  no  roughening,  although  they  may  be  thickened 
at  the  ends. 

Prognosis. — The  prognosis  is  good  if  the  child  comes  under  obser- 
vation early,  and  treatment  is  carried  out  thoroughly. 

Treatment. — Syphilitic  bone  lesions  in  children  respond  strikingly 
to  mercury  and  the  iodides.  A  child  five  years  of  age  should  be  given 
from  3^  to  -2V  of  ^  grain  of  bichloride  of  mercury  daily,  with  from  12  to 
20  grains  of  potassium  iodide  daily,  the  drugs  being  given  in  separate 
mixtures.  If  the  bichloride  of  mercury  given  by  the  stomach  disagrees, 
from  20  to  30  grains  of  mercurial  ointment  may  be  well  rubbed  into 
the  skin  daily.  In  order  to  prevent  gastric  disturbance,  the  adminis- 
tration of  potassium  iodide  should  be  interrupted  for  a  few  days 
every  month;  later  these  drugs  may  be  given  alternately.  The  part 
should  be  protected  locally,  and  placed  at  rest.  Suppuration  calls 
for  surgical  intervention  with  removal  of  the  dead  bones. 


Fig.  52. — Tuberculous  dactylitis  of  ring  finger. 


DACTYLITIS. 

Dactylitis  is  a  disease  of  the  phalanges  in  children,  causing  a  fusiform 
swelling,  and  may  be  syphilitic  or,  rarely,  tuberculous.  It  may  also 
be  due  to  streptococcic  infection  or  trauma. 

Pathology. — In  both  tuberculous  and  syphilitic  forms  the  process, 
which  is  a  rarefying  osteomyelitis,  begins  in  the  centre  of  the  bone, 


CRANIOTABES 


521 


resulting  in  an  enlargement  of  the  medullary  canal,  while  at  the  same 
time  there  is  a  proliferative  periostitis,  causing  a  fusiform  enlargement. 
Suppuration  and  necrosis  occur,  and  a  finger  or  toe  may  be  lost. 
An  acute  dactylitis,  arising  from  streptococcic  infection  or  trauma, 
presents  the  symptoms  of  acute  osteomyelitis. 

Diagnosis. — Syphilitic  dactylitis  is  more  common  than  the  tuber- 
culous form.  It  occurs  most  frequently  during  the  first  two  years  and 
usually  involves  several  bones.  The  proximal  phalanges  are  apt  to  be 
involved  in  syphilis,  and  there  is  not  the  tendency  to  affect  the  meta- 
carpals, seen  in  tuberculosis.  There  is  rarely  suppuration,  and  the 
surrounding  tissues  are  usually  not  involved  if  the  type  be  syphilitic. 

In  the  tuberculous  form  metacarpals  and  phalanges  are  involved. 
There  is  tumefaction,  due  mostly  to  swelling  of  the  soft  tissues,  and  the 


Fig.  53.- 


-Syphilitic  dactylitis  involving  all  fingers  and  thumb  of  left  hand 
and  thumb  of  right  hand. 


part  is  tender.  The  tuberculous  lesions  are  less  apt  to  be  multiple. 
The  history  of  the  case,  the  presence  of  concomitant  symptom.s  of  either 
disease,  and  the  Wassermann  and  von  Pirquet  tests  are  additional 
aids  to  diagnosis. 

Prognosis.— The  underlying  constitutional  disease  should  be  treated 
at  once.  Locally  the  part  should  be  put  at  rest  and  kept  immobile 
by  splints  for  months.  Abscess  formation  and  necrosis,  if  they  occur, 
require  surgical  intervention. 


CRANIOTABES. 


Craniotabes  is  a  condition  characterized  by  the  presence  of  soft 
spots  of  thinning  in  the  cranial  bones.  It  may  be  due  to  several  causes. 
Syphilis  is  found  in  over  50  per  cent,  of  the  cases.    Rachitis  is  also 


522  DISEASES  OF  THE  BONES  AND  JOINTS 

present  quite  frequently,  and  the  most  marked  cases  are  seen  in  chil- 
dren with  both  syphilis  and  rachitis.  It  may  occur  in  hydrocephalus 
of  the  chronic  type. 

In  a  certain  percentage  of  the  cases,  no  underlying  condition  can 
be  found  to  account  for  the  craniotabes.  These  areas  are  found  in  the 
parietal  and  occipital  bones.  They  are  caused  by  bony  absorption 
which  begins  on  the  inner  table  of  the  skull,  and  is  supposed  to  be  due 
to  pressure  of  the  brain  internally,  and  the  pillow  externally. 

BOSSING  OF  THE  SKULL. 

Bosses  on  the  bones  of  the  vault  of  the  skull  are  caused  most  fre- 
quently by  rachitis  or  syphilis.  The  most  marked  cases  are  seen  in 
children  where  both  these  etiological  factors  are  present.  This  con- 
dition is  due  to  exuberant  formation  of  bone  around  the  centres  of 
ossification. 

Bosses  are  usually  found  on  the  frontal  and  parietal  bones,  but  may 
occur  in  the  occipital  and  temporal  regions.  They  may  be  confused 
with  the  osteoperiostitis  of  the  bones  of  the  skull  seen  in  tuberculosis. 
Among  the  rarer  causes  of  bossing  are  achondroplasia,  hereditary 
cleidocranial  dystosis  and  tumors. 

ACUTE  ARTHRITIS  OF  INFANTS. 

This  disease  is  also  known  as  acute  purulent  synovitis  and  acute 
epiphysitis.  It  is  a  form  of  pyemia  resulting  in  an  acute  inflammation 
of  the  joints  with  suppuration.  The  majority  of  cases  occur  during  the 
first  year,  and  most  of  these  are  seen  during  the  first  six  months  of  life. 
The  disease  m.ay  begin  in  the  epiphysis  or  medullary  canal,  but  the 
joint  is  soon  involved,  the  natiu-e  of  the  arthritis  depending  upon  the 
infecting  organism..  The  gonococcus  causes  an  inflammation  of  the 
joint  proper,  and  the  synovial  mem.brane  is  involved,  but  there  are  no 
destructive  changes  in  the  cartilage,  ligaments,  or  bone. 

The  cases  due  to  the  staphylococcus  or  streptococcus  are  more 
severe,  and  the  joint  may  be  destroyed.  The  suppurative  process 
shows  a  tendency  to  spread,  and  may  result  in  diffuse  osteomyelitis, 
subperiosteal  abscess,  or  even  a  separation  of  the  epiphysis.  The 
final  outcome  is  either  a  flail  joint  or  bony  ankylosis. 

Etiology. — The  infection  is  hematogenous,  and  m.ay  occur  very 
soon  after  birth  from  an  infected  umbilicus.  During  the  later  months 
of  infancy  the  organism.s  m.ay  enter  the  blood  stream  through  abrasions 
of  the  skin  or  from  the  conjunctiva,  genital  tract  or  mouth.  In  some 
cases  the  portal  of  entrance  cannot  be  dem.onstrated.  The  staphylo- 
coccus, streptococcus,  gonococcus,  and  pneum.ococcus  have  been 
isolated. 

Symptoms. — The  constitutional  symptoms  are  marked,  and  usually 
precede  local  signs.  There  is  high  fever,  malaise,  anorexia,  and 
vomiting.     Following   this,    one   or   several   joints   become   swollen, 


TUBERCULOSIS  OF  JOINTS  523 

painful  and  tender.  The  overlying  skin  is  reddened,  and  the  local 
temperature  increased.  Suppuration  occurs  rapidly,  and  fluctuation 
may  be  present. 

In  severe  cases,  a  general  pyemia  m.ay  develop,  with  visceral  com- 
plications, such  as  pneumonia,  pericarditis,  or  meningitis.  In  milder 
cases,  the  abscesses  continue  to  grow  larger  and  suppuration  is  con- 
fined to  the  joints.  In  the  gonococcic  form  there  may  be  no  suppu- 
ration. 

Diagnosis. — Some  cases  resemble  acute  rheumatic  fever,  but  there 
is  no  endocarditis,  and  the  joint  lesions  are  much  more  severe.  Syphil- 
itic and  tuberculous  epiphysitis  are  very  much  more  chronic  in  nature, 
the  symptoms  are  not  as  severe,  and  other  evidences  of  these  diseases 
are  present. 

Treatment. — Cold  compresses  should  be  applied  locally  for  relief 
of  pain.  When  fluctuation  is  apparent,  free  evacuation  of  the  pus 
should  be  obtained  by  an  incision  into  the  joint  cavity.  This  should  be 
followed  by  fixation  of  the  joint.  Life  is  often  saved  by  prompt 
evacuation  of  pus,  but  the  function  of  the  joint  is  usually  impaired. 

TUBERCULOSIS  OF  JOINTS. 

-  Tuberculosis  is  the  most  frequent  infection  of  joints  during  childhood, 
and  is  usually  secondary  to  tuberculosis  of  the  epiphysis.  In  some  cases 
there  may  be  no  demonstrable  foci  of  tuberculosis  anywhere  else  in 
the  body.  The  process  is  essentially  chronic,  but  an  acute  tuberculous 
osteomyelitis  ro.ay  sometimes  be  observed  in  miliary  tuberculosis. 

Symptoms. — The  onset  is  insidious,  and  the  earliest  symptoms  may 
not  be  noticeable  to  the  parent.  Pain  is  indefinite,  quite  obscure, 
intermittent,  and  referred  to  m.ore  or  less  rem.ote  parts.  Impairment  of 
function  and  atrophy  of  the  muscles  connected  with  the  joint  together 
with  characteristic  night  cries  are  among  the  earlier  symptoms.  The 
joint  may  become  swollen,  and  there  is  tenderness  on  pressure. 

Spasm  of  the  muscles  surrounding  an  affected  joint  is  one  of  the  most 
constant  sym.ptom.s.  Rigidity  is  not  present  until  the  later  stages  of 
the  disease,  and  fluctuation  cannot  be  detected  until  the  destructive 
process  is  well  advanced.  The  constitutional  symptoms  are  night 
sweats,  night  cries,  anemia,  anorexia,  and  a  slight  afternoon  tem- 
perature. 

Diagnosis. — ^Intermittency  of  symptom.s  often  causes  delay  in  arriv- 
ing at  a  correct  diagnosis.  The  chronic  nature  of  a  tuberculous 
arthritis  distinguishes  it  from  acute  inflammatory  rheumatism,  and 
acute  infectious  arthritis.  Syphilitic  arthritis  is  very  rare,  and  is  usu- 
ally manifested  by  a  bilateral  effusion  of  the  knee-joints.  It  responds 
quickly  to  the  mercurials  and  iodides,  so  that  the  therapeutic  test  is  of 
value  in  the  differentiation.  In  syphilis  the  Wassermann  reaction 
will  be  found  positive,  and  concomitant  signs  may  be  in  evidence.  A 
positive  von  Pirquet  reaction,  and  the  presence  of  other  foci  of 
tuberculosis  mav  be  demonstrated  in  tuberculous  arthritis. 


524  DISEASES  OF  THE  BONES  AND  JOINTS 

Prognosis. — The  prognosis  is  good  if  treatment  is  instituted  early, 
and  the  destructive  process  stopped;  otherwise,  the  condition  grows 
steadily  worse,  and  complete  disorganization  of  the  joint  may  result. 
Complete  recovery  with  little  or  no  impairment  of  motion  is  often 
obtained  under  careful  management. 

Treatment. — The  treatment  of  uncomplicated  cases  of  joint  tuber- 
culosis is  conservative.  This  conservative  treatment  of  bone  tuber- 
culosis in  the  child  is  extremely  important.  The  tuberculous  process 
in  children  almost  invariably  begins  in  the  epiphysis  or  the  juxta- 
epiphyseal  region.  Active  operative  interference  on  the  epiphysis 
interferes  with  the  subsequent  growth  in  the  length  of  the  bone,  which 
is  a  matter  of  vital  importance. 

Local  pain,  swelling,  effusion  into  the  joint,  and  fever  do  not 
necessarily  point  to  operative  interference  unless  pyogenic  bacteria 
are  present,  with  a  resulting  formation  of  pus.  Of  course,  if  pyogenic 
pus — not  tuberculous  pus — is  present,  an  opening  must  be  made  and 
the  pus  removed. 

Absolute  rest  to  the  joint,  life  in  the  open  air,  good  food,  and  appro- 
priate tonics,  with  plenty  of  time,  will  accomplish  a  great  deal  in 
children.  This  elem.ent  of  time  is  less  important  in  the  child  than 
in  the  adult;  usually  the  adult  is  a  wage-earner,  and  the  loss  of  time 
is  a  more  serious  matter.  The  joint  should  be  put  at  rest  in  a  plaster- 
of-Paris  cast,  but  weight  bearing  has  been  proven  not  to  be  injurious 
when  proper  fixation  of  the  joint  is  secured.  Passive  hyperemia,  if 
used  carefully  and  systematically,  is  of  benefit  in  the  earlier  stages  of 
the  disease.    Tuberculin  is  often  administered  with  good  results. 

In  the  later  stages,  when  the  joint  becom_es  destroyed  and  systemic 
sym.ptoms  are  marked,  arthrectomy  may  be  considered  but  is  rarely 
advisable.  Cold  abscesses  are  complications  in  about  50  per  cent,  of  the 
cases  of  tuberculous  arthritis,  and  when  they  occur  they  should  not 
be  opened  except  when  spontaneous  rupture  is  inevitable.  The  child 
with  a  tuberculous  lesion  in  a  joint  should  be  put  under  the  most 
hygienic  living  conditions,  and  everything  possible  should  be  done  to 
improve  the  general  health.  Life  at  the  seashore  is  of  special  benefit 
to  these  children. 


CHAPTER    XIX. 
DISEASES  OF  THE  GENITO-URINARY  SYSTEM. 


DISEASES  OF  THE  KIDNEY. 

THE   URINE. 

The  infant  usually  micturates  within  twelve  hours  after  birth, 
and  in  many  cases  micturition  occurs  spontaneously  with  birth. 
Certain  constituents  of  urine  are  found  in  the  liquor  amnii,  indicating 
intra-uterine  activity  of  the  kidneys,  if  not  actual  urination.  The 
bladder  normally  contains  urine  at  birth.  The  amount  of  urine  passed 
daily  and  the  specific  gravity  and  percentage  of  the  different  constit- 
uents vary  greatly  during  infancy,  as  wel)  as  during  the  greater  part 
of  childhood. 

Quantity. — The  quantity  of  urine  passed  for  the  first  three  days 
corresponds  to  the  amount  of  liquids  ingested.  At  each  evacuation 
of  the  bladder  from  ^  to  f  of  an  ounce  is  passed,  with  a  total  quantity 
of  from  2  to  3  ounces  in  twenty-four  hours.  With  the  establishment 
of  breast-feeding,  the  amount  of  urine  increases  with  each  succeeding 
day,  and  at  the  end  of  the  first  week  the  daily  output  is  about  8 
ounces.  At  six  months,  the  average  daily  quantity  of  urine  passed  is 
about  12  ounces,  and  at  two  years  16  ounces.  From  the  second  year 
onward  the  daily  output  of  urine  increases  1|  ounces  each  year  until 
the  child  is  twelve  years  of  age.  There  is  an  increased  quantity  of 
urine  in  diabetes  mellitus  and  chronic  interstitial  nephritis,  and  a 
decrease  in  renal  congestion  and  acute  nephritis. 

Children  pass  relatively  larger  amounts  of  urine  than  adults.  Nor- 
mally micturition  occurs  often  during  infancy,  and  a  baby  may  urinate 
from  ten  to  fifteen  times  a  day  under  ordinary  circumstances.  There 
is  great  difficulty  in  collecting  a  twenty-four-hour  specimen  in  children 
because  of  this  frequency  in  urination,  and  the  trouble  experienced 
in  securing  a  retainer  to  the  child  or  infant.  Male  infants  may  have 
a  condom  attached  to  the  penis,  or  a  wide-mouthed  bottle.  Absorbent 
cotton  may  be  used  to  collect  the  urine  of  female  infants.  These 
methods,  however,  all  expose  the  specimen  to  contamination,  and 
render  it  useless  for  bacteriological  study,  though  perfectly  reliable 
for  ordinary  chemical  tests.  To  obtain  an  unadulterated  specimen, 
a  No.  6  American  gauge  catheter  should  be  passed,  and  suprapubic 
pressure  made,  preferably  after  the  child  has  been  sleeping  for  a  long 
time. 


526  DISEASES  OF   THE  GEN  I  TO-URINARY  SYSTEM 

Specific  Gravity. — For  the  first  twenty-four  hours  the  specific  gravity 
averages  1005  to  1010,  for  the  child  does  not  ingest  much  hquid. 
When  nursmg  becomes  regularly  established,  the  specific  gravity 
falls  to  1003  or  1004,  and  remams  at  this  level  durmg  breast-feeding. 
From  the  second  year  the  specific  gravity  steadily  increases,  until 
at  puberty  it  ranges  from  1010  to  1015.  The  specific  gravity  is 
increased  by  diarrhea,  fever,  and  sweatmg. 

Reaction. — ^The  urine  at  birth  is  acid,  and  remains  famtly  acid,  nor- 
mally, throughout  life.  The  ingestion  of  an  alkaline  diet  will  change 
the  reaction  of  the  child's  urine,  and  a  diet  containing  too  much  fat 
may  cause  it  to  become  ammoniacal. 

Color. — The  color  of  the  urme  is  a  fair  indication  of  its  specific 
gravity,  a  pale  yellow  urine  usually  having  a  low  specific  gravity,  and 
a  high-colored  urme,  being  concentrated,  having  a  high  specific 
gravity.  The  urine  of  infancy  is  much  paler  than  during  childhood. 
In  fevers  the  urine  becomes  high-colored  and  turbid.  ^Milky-white 
urine  suggests  pus,  while  urine  of  a  reddish  hue  should  lead  one  to 
suspect  the  presence  of  blood.  Bile  is  sometimes  found  in  the  child's 
mine,  and  imparts  to  it  a  greenish-yellow  color. 

Hematuria. — Hematuria  is  the  term  applied  to  urine  that  contains 
blood  corpuscles  and  blood  pigment.  In  every  case  of  suspected  hema- 
turia a  microscopic  study  of  the  urine  should  be  made  to  determine 
the  presence  of  blood  corpuscles,  which  differentiate  this  condition 
from  hemoglobinuria.  While  the  causes  of  hematuria  are  many  and 
varied,  idiopathic  hematuria  is  quite  common  in  children.  These 
cases  are  miassociated  with  any  appreciable  constitutional  distm-b- 
ance,  and  no  organic  lesion  can  be  demonstrated  to  account  for  the 
appearance  of  the  blood.  They  usually  clear  up  m  a  day  or  two,  and 
are  sometimes  referred  to  as  renal  epistaxis.  In  some  instances  large 
quantities  of  blood  may  appear  in  the  mine  with  no  other  symptoms 
than  a  slightly  increased  frequency  of  urmation.  The  best  treatment 
for  these  cases  is  rest  in  bed,  mild  catharsis,  and  a  soft  diet. 

Hematuria  immediately  following  birth  may  be  due  to  the  passage 
of  uric  acid  crystals  and  infarcts,  to  hemorrhagic  disease  of  the  new- 
born, or  to  septic  infection.  After  uifancy  it  is  seen  most  frequently 
in  scarlet  fever,  t^-phoid  fever,  malaria,  variola,  scurvy,  purpura,  hemo- 
philia, and  leukemia.  The  mgestion  of  certain  drugs,  such  as  canthar- 
ides,  turpentme,  and  other  poisonous  substances  may  also  give  rise 
to  hematinia.  Blood  appearing  in  the  urine  may  have  come  from  the 
kidney,  ureter,  bladder,  urethra,  or  from  the  genital  tract.  When 
hematuria  has  its  origin  in  the  kidney,  urine  is  usually  abnormal  in 
color,  the  blood  impartuig  to  it  a  smokv  hue.  The  appearance  of  blood 
casts  in  the  urme  is  significant  of  renal  hematmia. 

The  most  common  causes  of  hemorrhage  from  the  kidney  are  the 
acute  infectious  diseases,  h>'peremia  of  the  kidney,  and  acute  nephritis. 
It  may  occm-  during  chronic  nephritis,  and  is  also  seen  in  association 
with  mfarcts,  tuberculosis  of  the  kidney,  neoplasms,  calculi,  parasites, 
angiomata,  abscesses,  embolism,  and  cysts. 


THE   URINE  527 

Hemorrhage  from  the  m-eter  is  usually  caused  by  the  passage  of  a 
stone  or  by  neoplasms.  Blood  which  comes  from  a  lesion  of  the  bladder 
is  usually  normal  in  color,  and  sometimes  very  abundant.  It  is  gen- 
erally due  to  either  tuberculosis  of  the  bladder,  vesical  calculi,  or 
neoplasms.  The  blood  from  a  hemorrhage  of  the  urethra  is  normal, 
and  may  be  uncontaminated  with  urine.  It  may  be  due  to  traumatism 
from  stone  or  catheter,  and  in  some  cases  is  caused  by  gonorrhea. 
The  treatment  of  hematuria  consists,  for  the  most  part,  in  tracing 
the  source  of  the  hemorrhage,  and  removing  its  cause.  Rest  in  bed, 
mild  purgation,  and  a  light  diet  are  also  beneficial. 

Hemoglobinuria. — Hemoglobinuria  is  that  condition  in  which  blood 
pigment  only  is  found  in  the  urine,  no  blood  corpuscles  being  present. 
Hemoglobinuria  indicates  either  that  the  blood  cells  are  being  destroyed 
by  some  process  and  hemoglobin  is  being  set  free  in  the  circulation, 
or  that  the  hemoglobin  is  being  dissolved  out  of  the  blood  cells  and 
passes  into  the  circulation.  Hemoglobinuria  in  epidemic  form  occurs 
in  the  newborn,  being  known  as  Winckel's  disease.  It  may  be  pro- 
duced by  the  ingestion  of  poisons  such  as  potassium  chlorate  or  car- 
bolic acid.  It  is  occasionally  observed  in  the  course  of  yellow  fever, 
typhoid  fever,  malaria,  and  scarlatina,  and  occm-s  in  children  affected 
with  scurvy,  inherited  syphilis,  or  purpura. 

There  is  a  paroxysmal  form  of  hemoglobinuria  in  which  the  cause 
is  unknown.  The  attacks  are  accompanied  by  chills,  dyspnea,  pal- 
pitation, and  cyanosis.  It  is  thought  that  the  individual  carries  the 
hemolysin  in  his  own  blood,  but,  in  addition,  cold  and  exertion  are 
necessary  to  precipitate  an  attack.  Syphilis  is  regarded  as  a  factor 
in  this  type  of  hemoglobinuria,  having  been  found  associated  in  50 
per  cent,  of  the  cases  of  the  disease. 

The  treatment  of  hemoglobinuria  is  to  remove  the  cause  and  support 
the  child's  strength  by  plenty  of  rest  and  a  good  nourishing  diet. 
Syphilis  should  be  suspected  in  every  case,  and  upon  its  discovery 
antisyphilitic  measures  at  once  instituted. 

Functional  Albuminuria  {Postural  Albuminuria,  Cyclic  Albuminuria, 
Orthotic  xilbuminuria) . — Functional  albuminuria  occurs  principally 
in  children,  and  is  characterized  by  the  presence  of  sero-albumin  in 
the  urine  in  the  latter  part  of  the  forenoon  and  afternoon  only.  It 
disappears  after  a  night's  rest.  The  term  "cyclic  albuminuria" 
designates  its  regular  appearance  at  certain  hoius  of  the  day,  and 
"postural  albuminuria"  that  the  erect  posture  on  arising  is  a  factor 
in  its  production.  Albuminuria  has  been  observed  frequently  in  chil- 
dren with  lordosis  of  the  lumbar  vertebrae,  and  is  sometimes  referred 
to  as  lordotic  albuminuria. 

Symptoms. — Children  who  give  evidence  of  functional  albuminuria 
are  usually  neurasthenic,  and  have  an  anemic  appearance.  They 
complain  of  vague  pains,  headache,  and  sometimes  nausea.  There 
is  a  lack  of  tone  in  the  involuntary  muscles.  Dilatation  of  the  stomach 
and  heart  are  common.  The  pulse  tension  is  low;  the  hands  frequently 
become  cyanosed.     Many  of  these  little  ones  suffer  from  epistaxis. 


528  DISEASES  OF   THE  GEN  I  TO-URINARY  SYSTEM 

On  the  other  hand,  functional  albuminuria  may  be  observed  in  chil- 
dren apparently  enjoying  good  health. 

Diagnosis. — A  diagnosis  of  functional  albuminuria  should  be  made 
only  after  careful  consideration  and  the  exclusion  of  any  signs  con- 
firmative of  pathological  albuminuria.  Its  most  distinguishing 
features  are  the  entire  absence  of  symptoms  of  nephritis  and  of  casts 
in  the  urine,  also  the  effects  of  rest  on  this  condition. 

Treatment. — Recovery  from  functional  albuminuria  is  often  slow, 
but  is  the  rule.  It  may  be  hastened  by  a  change  of  residence  to  a 
healthful,  invigorating  climate,  and  careful  regulation  of  the  diet  to 
increase  nutrition.  Strychnine  sulphate,  in  tonic  doses  of  2^^  to  y^-g- 
of  a  grain,  taken  twice  daily,  is  of  recognized  value  in  this  con- 
dition. 

Paroxysmal  Albuminuria. — Paroxysmal  albuminuria  may  be  recog- 
nized as  one  of  the  forms  of  functional  albuminuria.  It  is  most  fre- 
quently observed  in  connection  with  paroxysmal  hemoglobinuria. 
There  are  no  associated  symptoms  of  nephritis  during  an  attack,  and 
the  urine  contains  no  casts.  Between  attacks,  which  usually  last 
two  or  three  days,  the  child  enjoys  good  health. 

Lithuria. — An  excess  of  uric  acid  bodies  in  the  urine  is  termed 
lithuria.  It  is  common  in  children  from  birth  to  puberty,  and  indi- 
cates an  increased  amount  of  uric  acid  in  the  blood  and  tissues.  Since 
the  deposition  of  amorphous  sediments  of  urates  as  the  urine  cools 
is  a  common  event,  and,  in  view  of  the  fact  that  such  trivial  causes 
as  mere  concentration  of  the  urine,  or  an  increased  acidity,  or  the  tem- 
perature of  the  air,  may  precipitate  these  uric  acid  bodies,  the  amount 
of  the  sediment  must  not  be  interpreted  as  indicative  of  the  amount 
of  uric  acid  output. 

Symptoms. — During  infancy  the  urine  contains  a  comparatively 
small  amount  of  urea,  but  the  uric  acid  output  is  high;,  in  some  cases 
the  minute  crystals  coalesce  and  form  calcareous  masses.  The  passage 
of  these  masses  and  of  uric  acid  infarcts  may  cause  considerable  abdom- 
inal colic,  with  tenderness  over  one  kidney.  The  irritation  produced 
by  these  bodies  is  evinced  by  the  appearance  of  blood,  of  albumin, 
and  even  of  casts  in  the  urine.  In  infants  there  may  be  slight  hemor- 
rhage, giving  rise  to  actual  hematuria  for  a  week  or  so  during  the 
excretion  of  crystallme  uric  acid. 

A  mild  inflammation  of  any  part  or  of  the  entire  urinary  tract  is 
sometimes  shown  by  the  presence  of  large  numbers  of  epithelial 
cells,  leukocytes,  and  red  blood  corpuscles,  also  of  mucus.  After 
infancy  an  excess  of  urates  in  the  urine  is  not  so  frequent;  but  in 
nervous,  irritable,  anemic  children  there  may  be  recurrent  attacks 
throughout  childhood.  It  is  sometimes  observed  in  chorea,  chronic 
dyspepsia,  malnutrition,  rheumatism,  and  scurvy,  and  always  indicates 
severe  nutritional  disturbance.  The  microscopic  features  of  the 
urinary  sediment  in  lithuria  are  large  numbers  of  uric  acid  crystals 
and  a  moderate  collection  of  calcium  oxalate  crystals.  A  simple  test 
is  the  application  of  heat  to  a  specimen  of  urine,  whereupon  the  tur- 


THE   URINE  529 

bidity  will  disappear  and  the  sediment,  if  composed  of  uric  acid  or 
urates,  will  be  dissolved. 

Treatment. — Regulation  of  the  diet  is  impossible  during  infancy 
as  the  child  should  be  kept  on  the  breast;  but  older  children  may  be 
placed  on  a  diet  that  is  poor  in  purin  substances.  Alkaline  diuretics 
are  indicated,  and,  to  a  child  of  three  years,  5  grains  of  potassium 
bicarbonate,  or  3  grains  of  potassium  citrate,  may  be  given  four 
times  a  day  to  advantage. 

Acetonuria. — Acetone  is  found  in  minute  quantities  in  normal  urine, 
but  may  be  considerably  increased  in  many  pathological  conditions. 
In  children  acetonuria  is  induced  by  slight  causes,  of  which  changes 
in  the  diet  are,  perhaps,  most  common.  The  chief  cause  of  the  for- 
mation of  acetone  is,  apparently,  the  withdrawal  of  carbohydrates 
from  the  food,  or  inability  to  utilize  carbohydrates.  That  carbohy- 
drates alone  are  not  the  only  factors  in  the  production  of  acetonuria 
is  demonstrated  by  the  increased  acetonuria  caused  by  a  diet  rich  in 
fats;  and,  in  view  of  most  recent  experimental  research,  there  seems 
to  be  no  doubt  that  the  proteins  of  the  food  and  tissues  must  be 
looked  upon  as  contributing  to  the  total  yield  of  acetone. 

The  frequency  of  acetonuria  in  diabetics  need  not  be  emphasized; 
but  it  also  occurs  in  malignancy,  prolonged  fevers,  starvation,  diges- 
tive disturbances  (especially  when  associated  with  persistent  vomit- 
ing), and  is  frequently  associated  with  bronchopneumonia.  The 
appearance  of  acetone  in  the  urine  of  epileptics  has  no  bearing  on  the 
convulsive  seizures,  and  though  the  association  of  acetonuria  with 
cyclic  vomiting  is  as  yet  not  clearly  understood,  it  is  thought  to  be 
the  result  of  the  persistent  vomiting,  rather  than  the  cause. 

Symptoms. — The  most  important  symptoms  of  acetonemic  acidosis 
are  dyspnea,  or  air -hunger,  rapid  pulse,  and  in  fatal  cases  coma. 
The  diagnosis,  however,  is  based  on  an  examination  of  the  urine  which 
reveals  the  presence  of  acetone  and,  perhaps,  its  kindred  bodies — 
diacetic  acid  and  oxybutyric  acid.  The  presence  of  acetone  is  indi- 
cated by  the  well-known  iron  reaction;  i.  e.,  the  development  of  a 
deep  red-brown  color  on  the  addition  of  a  solution  of  ferric  chloride 
to  a  specimen  of  urine. 

When  patients  are  taking  salicylates  or  aspirin  this  reaction  is,  of 
course,  masked  by  the  iron  reaction  due  to  the  drug.  If  doubt  exists 
as  to  the  cause  of  the  reaction,  the  urine  should  be  boiled  for  a  few 
minutes,  and  the  test  repeated  after  it  has  cooled.  As  a  result  of  such 
treatment  acetoacetic  acid  will  be  broken  up  into  acetone  and  carbon 
dioxide,  and  the  reaction  will  no  longer  be  obtained. 

Treatment. — The  first  thing  to  be  done  in  a  severe  case  of  acetonuria 
combined  with  great  acidosis  is  to  give  a  purge  of  calomel,  2  grains  to 
a  child  of  three  years,  followed  by  a  saline  cathartic;  magnesium  sul- 
phate, 1  dram  every  two  hours  until  free  catharsis  is  produced,  would, 
perhaps,  be  better.  In  addition  to  this,  two  measures  are  clearly 
indicated — the  administration  of  alkalies  to  neutralize  the  acidosis 
and  the  giving  of  easily  assimilable  carbohydrates,  such  as  levulose 
34 


530  DISEASES  OF   THE  GEN  I  TO-URINARY  SYSTEM 

or  glucose.  Sodium  bicarbonate  is  probably  the  most  efficient  alkali, 
and  should  be  given  in  30-grain  doses  with  glucose  by  the  mouth, 
unless  there  be  persistent  vomiting,  when  both  of  these  drugs  may  be 
given  in  solution  by  rectum.  Fresh  air,  outdoor  exercise,  and  massage 
are  all  beneficial,  and  prophylactic  measures  to  promote  convalescence. 

Indicanuria. — Indican  is  found  in  minute  quantities  in  the  normal 
urine  when  a  mixed  diet  is  being  ingested,  and  may  be  much  increased 
by  a  protein  diet,  since  it  is  derived  from  the  proteins  of  the  food 
which  are  in  part  decomposed  in  the  intestine  by  bacteria.  It  may 
also  be  produced  by  conditions  in  which  the  cavities  of  the  body  con- 
tain fetid  pus,  as  in  fetid  empyema  and  pulmonary  abscess.  With 
this  exception,  indicanuria  may  be  considered  a  sign  of  bacterial 
disintegration  of  proteins  in  the  intestinal  canal,  and  the  amount  of 
indican  in  the  urine  as  an  index  of  the  extent  of  this  putrefaction. 

Although  indicanuria  is,  in  most  cases,  due  to  either  acute  or  chronic 
intestinal  derangement,  it  is  also  frequently  observed  in  chorea,  typhoid 
fever,  peritonitis,  epilepsy,  and  malignancy.  It  is  especially  common 
in  tuberculous  enteritis,  and  has  also  been  found  m  association  with 
urticaria  and  other  skin  diseases.  Indican  is  usually  absent  in  the 
urine  of  normal  breast-fed  babies,  but  appears  soon  after  infancy;  it 
is  much  increased  by  constipation  or  masturbation,  so  that  a  strong 
indican  reaction  in  children  is  always  of  pathological  significance. 

In  testing  for  indican  it  is  essential  that  a  freshly  voided  specimen 
of  urine  be  used,  as  indican  rapidly  disappears  on  standing,  and 
renders  an  accurate  estimate  of  the  quantity  of  indican  impossible. 
If  tested  accurately,  the  quantity  of  indican  may  serve  as  a  guide  to 
the  severity  of  the  associated  disease  and  the  effects  of  treatment. 
The  presence  of  indican  is  detected  by  adding  to  10  c.c.  of  normal 
urine  an  equal  volume  of  hydrochloric  acid  and  1  or  2  drops  of  liquor 
sodse  chlorinatae,  or  3  drops  of  aqua  hydrogenii  dioxide,  or  a  small 
pinch  of  sodium  perborate.  On  standing  several  hours,  the  color 
changes  to  a  bluish  hue  from  the  formation  of  indigo  blue.  By  shak- 
ing with  1  c.c.  of  chloroform,  the  indigo  dissolves  and  settles  as  a 
blue  bottom  layer,  when  the  amount  of  indican  may  be  estimated  by 
the  depth  of  the  color. 

Treatment. — The  indications  for  treatment  are  to  control  the 
putrefactive  process  going  on  in  the  intestinal  tract  by  the  same 
measures  referred  to  in  the  treatment  of  chronic  intestinal  indigestion 
and  constipation. 

Glycosuria. — Normal  urine  contains  such  a  minute  quantity  of 
glucose  that  a  positive  reaction  can  not  be  obtained  by  the  usual  tests. 
Occasionally  an  appreciable  amount  may  be  detected  in  the  urine 
of  apparently  healthy  children;  but  this  is  usually  a  physiological  gly- 
cosuria, the  result  of  the  ingestion  of  an  excessive  quantity  of  carbo- 
hydrates. A  pathological  glycosuria,  which  is  temporary,  sometimes 
occurs  in  affections  of  the  heart,  lungs,  liver,  brain,  and  spinal  cord; 
but  when  sugar  is  present  in  the  urine  in  appreciable  amount  we  are 
dealing  with  diabetes  mellitus.    The  urine  of  infants  fed  on  artificial 


THE    URINE  531 

preparations  frequently  gives  a  positive  reaction  for  sugar;  and  in 
some  breast-fed  babies  the  urine  responds  to  Fehling's  test,  but  not 
to  the  fermentation  test,  showing,  perhaps,  the  presence  of  lactose  and 
not  glucose. 

Fehling's  Test. — Fehling's  solution,  used  for  this  test,  deteriorates 
on  standing,  hence,  for  preserving,  it  is  best  made  in  two  parts,  and 
put  in  separate  bottles;  in  this  way  it  may  be  kept  indefinitely.  In 
one  bottle,  marked  No.  1,  keep  the  following: 

Pure  copper  sulphate "  .       .       .        17.32  grams 

Distilled  water .      250.00  c.c. 

In  another  bottle,  marked  No.  2: 

Fehling's  Alkaline  Solution. 

Rochelle  salt 87.0    grams 

Caustic  soda       .       . 25 . 0         " 

Distilled  water \      250.0    c.c. 

To  make  this  test,  mix  in  a  test-tube  equal  volumes  of  Nos.  1  and  2, 
dilute  with  an  equal  quantity  of  water,  and  boil.  No  precipitate 
should  be  noticed.  Now,  slowly  add  to  this  mixture  half  its  volume 
of  urine,  and  again  boil.  The  presence  of  glucose  will  be  indicated  by 
an  orange  or  red  precipitate. 

Pyuria. — Pyuria  is  that  condition  in  which  pus,  from  any  cause 
whatsoever,  is  found  in  the  urine.  In  children  its  origin  is  most 
frequently  the  bladder  or  pelvis  of  the  kidney,  but  it  may  come  from 
any  part  of  the  genito-urinary  tract,  or,  in  exceptional  cases,  from 
extraneous  sources.  This  latter  instance  is  best  demonstrated  by  the 
rupture  of  a  perinephric  or  appendiceal  abscess  into  some  portion  of 
the  genito-m'inary  tract. 

The  appearance  of  urine  containing  pus  depends  upon  the  quantity 
present  and  upon  its  reaction.  Iii  acid  urine,  in  which  pus  is  usually 
of  renal  origin  or  due  to  the  Bacillus  coli  or  a  tuberculous  infection, 
the  pus  tends  to  settle  as  a  dense  deposit  of  a  yellowish  or  greenish 
hue.  In  alkaline  urine  the  pus  is  stringy  and  less  circumscribed,  and 
tends  to  cling  to  the  sides  of  the  containing  vessel;  it  usually  comes 
from  the  bladder.  In  pyonephrosis  the  discharge  of  pus  is  apt  to  be 
intermittent;  in  cystitis  it  is  fairly  constant;  and  when  due  to  the 
rupture  of  a  neighboring  abscess  into  the  inmary  tract  there  is  usually 
a  copious  discharge  of  pus  for  a  time,  followed  by  more  or  less  rapid 
cessation  of  the  pyuria.  Rarely,  during  childhood,  does  pus  in  the 
urine  come  from  the  genital  tract;  but,  exceptionally,  it  may  be  due 
to  purulent  urethritis  or  vulvovaginitis,  and  when  this  is  the  source 
the  pus  appears  in  flakes  and  is  mixed  with  mucus. 

The  only  positive  method  of  determining  the  presence  of  pus  in 
the  urine  is  by  means  of  the  centrifuge  and  microscope.  The  ropy 
condition  produced  by  the  addition  of  caustic  alkali  is  often  significant. 
The  nature  of  the  infection  is  of  considerable  importance,  but  can  be 
demonstrated  only  by  a  culture  from  a  catheterized  specimen. 


532  DISEASES  OF   THE  GEN  I  TO-URINARY  SYSTEM 

Treatment. — The  treatment  of  pyuria  depends  chiefly  upon  the 
cause.  Because  of  its  ehmination  in  the  urine,  hexamethylenamin  is 
of  value  in  every  case,  regardless  of  the  etiology.  A  child  two  years 
old  should  be  given  2  grains  every  four  hours. 

Dysuria. — Dysuria,  or  painful  urination,  is  not  uncommon  in 
children  and  infants,  and  may  be  due  to  a  variety  of  causes.  Hyper- 
acidity and  the  passage  of  large  quantities  of  oxalates  or  uric  acid 
crystals  frequently  give  rise  to  dysuria  during  infancy,  and  in  child- 
hood the  concentrated  urine  voided  during  fevers  may  be  just  as 
irritating.  Small  calculi  are  often  passed  by  children;  in  these  cases 
not  only  is  there  dysuria  but  severe  colic  attends  the  passage  of  the 
stone  down  the  ureter.  These  calculi  are  frequently  found  on  exam- 
ination to  be  lodged  in  the  anterior  urethra.  Dysuria  may  also  be 
caused  by  cystitis,  urethritis,  vulvovaginitis,  and  phimosis. 

In  rare  cases  one  meets  with  congenital  anomalies  which  may 
render  urination  difficult  and  painful.  In  female  infants  there  some- 
times exists  at  birth  a  membrane  which  covers  the  vaginal  orifice 
and  extends  over  the  urethral  meatus  with  but  a  minute  opening 
through  which  the  urine  may  filter  out  drop  by  drop.  In  these  cases, 
urination  is  accompanied  by  great  straining  and  pain,  but  the  mem- 
brane can  easily  be  divided  with  a  blunt  dissector,  which  procedure 
at  once  relieves  the  condition.  Urethral  caruncles  are  extremely  rare 
in  little  girls;  but  occasionally  in  little  boys  painful  micturition  is 
caused  by  a  condition  of  the  urinary  meatus  in  which  the  lips  of  the 
urethra  are  swollen  and  slightly  everted,  and  on  close  examination 
is  seen  a  small  bead  of  granulations,  which  is  very  sensitive.  The  best 
treatment  is  to  remove  the  granulations  and  stitch  up  the  wound. 

In  male  infants  there  is  occasionally  a  cellular  adhesion  of  the  pre- 
puce and  glans  penis,  or  a  thin  membrane  over  the  urethral  meatus, 
which  causes  difficult,  and  often  painful  micturition.  In  these  cases 
the  prepuce  should  be  freed  from  the  glans,  and  the  membrane  removed 
from  the  uretln-al  orifice.  Following  chcumcision,  a  painful  crack  or 
vesicle  sometimes  develops  near  the  meatus  and  makes  urination 
agonizing.  A  bland  antiseptic  ointment  will  protect  the  raw  surfaces 
from  the  urine,  and  effect  a  speedy  cure. 

Treatment. — The  treatment  of  dysuria  from  other  conditions  is 
directed  to  the  cause.  If  due  to  inflammatory  processes  along  the 
genito-urinary  tract,  dysuria  wifl  ameliorate  with  improvement  in 
the  local  condition;  when  due  to  hyperacidity,  dysuria  is  relieved 
by  the  administration  of  alkaline  diuretics  and  an  increased  intake 
of  water.  Potassium  citrate,  in  a  dose  of  4  grains,  t.  i.  d.,  in  plenty 
of  water,  to  a  child  of  five  years,  is  perhaps  the  most  efficacious  thera- 
peutic measure  to  be  employed  in  hyperacidity. 

Anuria. — Anuria  is  that  condition  in  which  the  kidneys  fail  to  secrete 
any  urine;  it  should  be  carefully  distinguished  from  retention  of 
urine,  in  which  affection  urine  is  normally  secreted  by  the  kidneys, 
but  is  retained  in  the  bladder.  When  anuria  occurs  in  the  course  of 
nephritis,  it  is  referred  to  as  "suppression  of  urine,"    In  rare  cases  it 


THE   URINE  533 

is  due  to  congenital  malformation  of  some  portion  of  the  urinary 
tract,  but  more  commonly  is  a  result  of  traumatism,  of  operative 
procedure,  of  the  passage  of  a  catheter,  or  the  administration  of  ether 
or  chloroform.  Complete  cessation  of  secretion  by  the  kidneys  has 
been  observed  in  cases  where  children  have  in  some  way  taken  phenol, 
phosphorus,  turpentine,  cantharides,  lead,  bichloride  of  mercury,  or 
other  violent  irritants  to  the  kidneys. 

Many  cases  of  anuria  during  infancy  cannot  be  accounted  for, 
although  it  is  believed  that  a  considerable  number  are  caused  by  uric 
acid  infarcts  of  the  kidney.  Occasionally  mere  chilling  of  the  body, 
a  gastro-intestinal  disturbance,  or  an  acute  infectious  disease  will 
be  the  only  demonstrable  cause  of  anuria.  Uremic  symptoms  appear 
very  late  in  children  with  anuria;  and  in  some  instances  in  which 
there  has  been  no  secretion  of  urine  for  ten  days  recovery  has  occurred. 
Unless  due  to  malformation  or  organic  disease  of  the  kidneys,  anuria 
rarely  persists  over  twenty-four  hours,  and  in  that  time  nothing 
abnormal  may  be  noticed  in  the  infant's  general  condition.  When 
urine  is  not  voided,  it  is  important  to  ascertain  whether  we  are  deal- 
ing with  retention  of  urine  or  anuria  before  attempting  to  treat  the 
condition.  This  distinction  can  easily  be  made  by  the  passage  of  a 
catheter,  which  will  reveal  a  full  bladder  in  retention,  and  an  empty 
one  in  anuria. 

Treatment. — The  general  measures  for  the  relief  of  anuria  are  hot 
fomentations  to  the  loins,  hot  baths,  and  free  purgation.  To  a  child 
four  years  old  1  dram  of  magnesium  sulphate  in  concentrated  solution 
is,  perhaps,  the  best  saline  cathartic  to  use.  Sweet  spirits  of  nitre, 
5  drops  every  hour,  and  potassium  citrate,  3  grains  hourly,  should 
be  administered  until  the  urinary  secretion  begins.  Colonic  flushing, 
using  normal  saline  solution  at  a  temperature  of  110°  F.,  is  often  a 
valuable  aid  to  this  medication.  Care  must  be  taken  not  to  inject 
too  much  fluid  into  the  colon  or  it  will  not  be  retained,  and  the  use 
of  one  pint  at  not  less  than  six-hour  intervals  is,  perhaps,  the  most 
efficacious  mode  of  employing  it. 

Retention  of  Urine. — Retention  of  urine  to  a  mild  degree  is  not 
uncommon  in  young  children,  but  rarely  does  a  case  come  under 
observation  which  requires  catheterization  for  relief.  It  may  be  the 
result  of  lodgment  of  a  stone  in  the  urethra,  of  lu-ethritis,  or  of  vagi- 
nitis. Phimosis,  when  extreme  and  due  to  edema  or  local  infection, 
also  reflex  painful  conditions  of  the  anus  and  rectum,  may  cause 
retention;  still  other  cases  are  due  to  myelitis,  injury  to  the  spinal 
cord,  or  hysteria.  Simple  retention  of  urine  not  due  to  organic  causes 
is  rarely  productive  of  any  symptoms,  and  may  not  cause  the  child 
the  slightest  inconvenience,  although  the  distended  bladder  may  be 
noticeable  on  inspection  of  the  abdomen,  and  on  percussion  may  be 
found  to  extend  to  the  umbilicus. 

Treatment. — Immediate  relief  of  retention  is  obtained  by  catheter- 
ization, but  this  is  not  always  necessary,  and  quite  frequently  a  small 
catheter  may  not  be  available.    A  No.  6  American  scale  catheter  may 


534  DISEASES  OF   THE  GENI TO-URINARY  SYSTEM 

1)0  used  for  infants,  ])iit  only  after  the  application  of  heat  to  the 
suprapubic  reji;ion  and  genitals  has  proven  ineffectual.  In  every  case 
the  exciting  cause  should  be  ascertained  and  treated.  In  myelitis, 
nothing  can  be  done  but  to  catheterize.  Hysterical  children  cease  to 
have  retention  when  their  nervous  systems  are  gotten  under  control, 
and  those  cases  caused  reflexly  by  painful  conditions  of  the  rectum 
and  anus  disappear  when  proper  treatment  is  directed  to  the  under- 
lying factor.  Not  infrequently  investigation  may  reveal  calculi  in 
the  anterior  urethra  of  children  which  will  clear  up  a  puzzling  case  of 
retention  for  which  no  other  cause  could  be  demonstrated. 

Polyuria. — Polyuria  is  a  temporary  condition  in  which  excessive 
quantities  of  urine,  are  passed.  It  is  a  symptom  of  diabetes  mellitus 
and  chronic  interstitial  nephritis,  and  when  chronic  is  called  diabetes 
insipidus.  Under  ordinary  conditions  an  increased  consumption  of 
fluid,  or  the  decreased  elimination  of  water  by  the  sweat  glands  or 
bowels,  will  naturally  result  in  polyuria,  and  certain  drugs,  among 
which  are  caffein,  diuretin,  and  digitalis,  materially  increase  the 
amount  of  urinary  secretion.  Polyuria  is  frequently  observed  in 
children  with  neurotic  tendencies,  and  is  often  induced  by  exposure 
to  cold  or  sudden  fright  iii  normal  children. 

The  absorption  of  dropsical  fluids  is  accompanied  by  polyuria,  and 
during  convalescence  from  fevers  children  are  apt  to  void  a  larger 
quantity  of  urine  than  usual.  An  interesting  case  is  reported  by  Fowler, 
of  a  child  who  merely  contracted  the  habit  of  drinking  large  quantities 
of  water,  and  who  had  polyuria  as  a  natural  sequence.  Chronic  poly- 
uria, or  diabetes  insipidus,  is  usually  due  to  organic  lesions,  and  this 
is  a  clinical  entity  quite  distinct  from  polyuria. 

Enuresis. — Enuresis  is  the  term  applied  to  incontinence  of  urine 
occurring  in  childhood,  and  is  due  to  involuntary  emptying  of  the 
bladder.  Incontinence  in  the  infant  is  normal;  but,  with  careful 
training,  continence  at  night  should  be  established  between  the 
second  and  third  years,  and  incontinence  after  the  third  year  should 
be  considered  abnormal,  and  so  treated.  Continence  during  the  day 
should  be  effected  even  earlier  if  the  child  receive  proper  training; 
after  it  is  eighteen  months  old  it  should  not  wet  itself  during  the 
day,  and  after  the  second  year,  if  awakened  and  placed  on  the  toilet 
twice  each  night,  there  should  be  no  bed  wetting. 

The  term  "nocturnal  enuresis"  is  applied  to  bed  wetting,  and  incon- 
tinence during  the  day  is  known  as  "diurnal  enuresis."  A  child  is 
most  apt  to  wet  the  bed  during  the  first  few  hours  of  sleep,  for  at  this 
time  sleep  is  most  profound,  and  it  is  not  awakened  by  the  desire  to 
empty  the  bladder.  Diurnal  enuresis  may  complicate  bed  wetting, 
and  these  cases  are  the  most  persistent  and  obstinate  to  treat;  but 
rarely  does  incontinence  during  the  day  exist  alone.  Nocturnal 
enuresis  is  usually  associated  with  pollakiuria  (frequent  urination) 
during  the  day,  and  diurnal  enuresis  when  not  associated  with  bed 
wetting  may  be  accompanied  by  incontinence  of  feces. 

Active   incontinence  is  said  to  be  present  when  sufficient  urine 


THE   URINE  535 

Hccumulates  in  the  bladder  to  cause  irritation  of  the  sensory  nerves, 
with  contraction  of  tlie  bladder  walls  from  dilatation  of  the  sphincter, 
resulting  in  a  full  stream  of  m'ine  which  is  rapidly  passed.  ^Yhen 
passive  incontinence  exists  there  is  weakness  or  paralysis  of  the 
sphincter  vesica^,  causing  a  continuous  dribbling  of  urine. 

Etiology. — By  far  the  greater  number  of  cases  of  enm-esis  have 
a  neurotic  basis,  and  it  is  only  exceptionally  that  an  organic  lesion, 
such  as  malformation  of  the  urinary  tract  or  paralysis  of  the  sphincter 
vesicae,  is  found  to  explain  this  condition.  Of  the  various  mal- 
formations which  cause  enuresis  little  need  be  said;  the  more  common 
ones  are  congenital  vesicovaginal  fistula,  persistence  of  the  urachus, 
extroversion  of  the  bladder,  and  a  congenitally  small  bladder.  Par- 
alysis and  deficient  nerve  innervation  of  the  sphincter  of  the  bladder 
are  observed  in  spina  bifida,  idiocy,  meningitis,  brain  tumor,  myelitis, 
and  injury  to  the  spinal  cord. 

Aside  from  these  comparatively  rare  cases,  due  to  organic  disease 
of  the  nervous  system,  there  is,  in  the  vast  majority  of  cases  of 
enuresis,  an  unstable  nervous  system  which  is  the  dii'ect  result  of  age 
and  heredity.  During  childhood  the  spinal  cord  and  especially  the 
motor  nerves  are  so  active,  and  the  brain  as  yet  so  comparatively 
undeveloped,  not  having  inhibitory  control  over  the  lower  centres, 
that  it  remains  only  for  some  slight  condition  which  will  increase  the 
irritability  of  the  spinal  centre  or  terminal  filaments  of  the  vesical 
nerves  or  interfere  w^ith  the  cerebral  control  over  this  centre  to  cause 
enuresis. 

The  importance  of  heredity  as  a  predisposing  factor  in  enuresis  is 
emphasized  by  the  number  of  children  wdth  enuresis  who  display 
various  other  neurotic  symptoms  which  indicate  inherited  neuro- 
pathic tendencies.  In  other  instances  the  central  nervous  system 
has  been  weakened  by  chronic  malnutrition,  due  either  to  improper 
feedmg,  unhygienic  surroundings,  enteritis,  tuberculosis,  or  syphilis. 
The  exciting  cause  of  an  initial  attack  is  often  an  acute  debilitating 
illness,  and  there  is  usually  a  recurrence  of  enuresis  after  such  an 
illness,  but  there  are  various  other  exciting  causes  of  enuresis. 

Whether  there  be  a  predisposition  to  enuresis  of  nervous  origin  or 
not,  one  will  often  find  one  of  the  following  conditions  to  account  for 
the  affection.  The  urine  itself  may  be  at  fault,  examination  revealing 
a  highly  acid  or  alkaline  reaction,  or  there  may  be  an  excess  of  oxalates 
or  uric  acid  crystals.  Occasionally  there  is  inflammation  somewhere 
along  the  genito-urinary  tract,  either  pyelitis,  cystitis,  or  urethritis; 
less  frequently  one  may  discover  calculi,  tumors,  or  polypi,  as  a  cause 
of  irritation.  Atony  of  the  bladder,  although  hard  to  demonstrate, 
unquestionably  exists  in  delicate,  undernourished  children;  and  in 
atony  as  well  as  in  abnormal  irritability  of  the  bladder  from  infection 
along  the  urinary  tract  or  irritation  of  nervous  origin,  may  lie  the 
explanation  of  many  obscure  cases  of  enuresis. 

Various  conditions  are  recognized  factors  in  producing  incontinence 
by   reflex  irritation;  they   comprise  balanitis,   vulvovaginitis,   rectal 


536  DISEASES  OF   THE  GENITO-URINARY  SYSTEM 

polypi,  fissure  in  ano,  intestinal  parasites,  and  constipation.  In  some 
cases,  conditions  even  more  remote,  such  as  enlarged  tonsils  and 
adenoids,  or  thj^roid  insufficiency,  may  be  considered  etiological 
factors.  Enuresis  dependent  upon  diabetes  mellitus  or  diabetes  insipi- 
dus, should,  perhaps,  be  attributed  to  the  excessive  quantity  of  urine 
excreted.  In  the  home  there  is  often  a  tendency  to  consider  enuresis 
as  purely  a  habit.  This  view  may  be  erroneous,  yet  it  is  quite  possible 
that  enuresis  may  be  the  result  of  faulty  training.  There  is  no  doubt 
that  once  the  condition  is  established,  its  continuance  is  largely  due 
to  habit,  a  fact  clearly  demonstrated  by  its  persistence  after  the 
recognized  cause  has  been  removed.  Frequently,  after  careful  study 
and  investigation  no  cause  can  be  found.  Eniuesis  occurs  with  equal 
frequency  in  boys  and  girls,  and  is  observed  at  all  ages  up  to  puberty, 
although  the  majority  of  cases  are  seen  before  the  fifth  year. 

Syn).ptoms. — Ordinary  enuresis  is  characterized  by  the  complete 
evacuation  of  the  bladder  in  a  full,  rapid  stream;  when  there  is  con- 
stant dribbling  an  organic  cause  may  be  strongly  suspected.  Noc- 
turnal incontinence  is  by  far  the  most  common  form,  and  may  or  may 
not  be  accompanied  by  pollakiuria,  while  in  diurnal  enuresis  pol- 
lakiuria  is  generally  present.  An  attack  of  enuresis  may  be  chronic, 
persisting  from  infancy  until  the  seventh  year;  or  it  may  be  recur- 
rent, each  attack  being  due  to  some  slight  disturbance.  Temporary 
attacks  are  thought  to  be  due  to  occasional  hypersensitiveness  of  the 
bladder.  The  act  of  bed  wetting  usually  occurs  in  the  early  evening 
when  sleep  is  most  profound,  and  in  the  morning  when  there  is  an 
accumulation  of  urine  in  the  bladder. 

Diagnosis. — ^The  diagnosis  is  self-evident,  and  is  made  by  the  child's 
parents. 

Prognosis. — The  prognosis  in  enuresis  depends  on  the  underlying 
cause;  but  the  age  of  the  child  and  the  duration  of  the  symptoms 
have  a  marked  influence  on  the  rapidity  of  the  cure.  When  there 
is  organic  disease  of  the  brain  or  cord,  or  when  malformations  exist 
which  are  beyond  surgical  intervention,  the  outlook  is,  of  course, 
hopeless.  In  the  absence  of  these  conditions  the  prognosis  as  to 
ultimate  recovery  is  good. 

If  some  cause  is  discovered  and  removed,  the  case  may  clear  up  in 
a  comparatively  short  time;  but,  as  a  rule,  months  of  systematic, 
thorough  treatment  are  required  to  bring  about  a  cure,  and  no  case 
should  be  pronounced  cured  until  a  year  has  elapsed  without  a  return 
of  the  condition.  Enuresis  shows  a  strong  tendency  to  cease  spon- 
taneously without  treatment  at  about  the  seventh  year;  for,  by  this 
time,  the  balance  of  the  nervous  system  is  fairly  well  established. 
Very  rarely  does  it  persist  after  puberty,  although  an  occasional 
instance  has  been  recorded  in  a  neurotic  girl. 

Treatment. — Prophylaxis  with  regard  to  enuresis  consists  in  early 
training  of  the  child  and  careful  supervision  of  its  habits  of  micturition 
and  defecation.  If  taught  to  control  its  bladder  and  make  known  its 
desire  to  empty  it,  the  child  should  have  the  mechanism  of  micturi- 


THE   URINE  537 

tion  under  cerebral  control  by  the  second  year.  Given  a  fully  devel- 
oped case  of  enuresis  to  treat,  the  physician  should  first  make  a  careful, 
systematic  search  for  any  condition  which  might  possibly  cause  it, 
inasmuch  as  treatment  directed  to  the  symptom  alone  is,  in  most 
cases,  a  failure. 

The  cooperation  and  confidence  of  the  parents  should  be  secm-ed 
by  telling  them  in  the  beginning  of  the  chronicity  of  enuresis  and  its 
stubborn  resistance  to  treatment.  It  is  obvious  that  any  predisposing 
cause  should  be  removed;  among  these  are  phimosis,  adherent  pre- 
puce, adherent  clitoris,  vaginitis,  vulvovaginitis,  urethritis,  pyelitis, 
pinworms,  rectal  polypi,  fissures  of  the  anus,  and  other  reflex  conditions. 

The  urine  should  always  be  examined,  and,  if  highly  acid,  the  diet 
should  be  regulated,  and  the  amount  of  proteins  decreased;  in  addi- 
tion, potassium  citrate  in  3-grain  doses  may  be  given  to  a  child  of 
three  years,  and  the  amount  of  liquids  increased  if  the  urine  is  too 
concentrated.  Excessive  alkalinity  may  result  from  a  diet  too  rich 
in  starch  and  sugar;  therefore,  if  this  cause  of  enuresis  be  discovered, 
it  is  well  to  limit  the  carbohydrate  intake,  and  to  give  benzoic  acid, 
2  grains  three  times  a  day,  to  a  child  tlu-ee  years  old.  If  the  quantity 
of  urine  passed  is  excessive,  the  amount  of  fluids  taken  by  the  patient 
must  be  restricted. 

Not  infrequently,  microscopic  examination  of  the  stained  sedi- 
ment of  a  specimen  will  reveal  the  presence  of  the  colon  bacillus, 
showing  an  infection  of  the  genito-urinary  tract  by  this  organism. 
Such  an  infection  is  accompanied  by  acidity  of  the  urine  and  a  highly 
irritable  bladder,  and  requires  the  administration  of  potassium  citrate 
and  urotropin,  of  each  3  grains  three  times  a  day,  to  render  the 
urine  less  irritating  and  inert. 

The  bladder,  itself,  should  be  examined  carefully,  and  if  atony  of 
the  sphincter  be  found,  galvanic  or  mild  faradic  currents  may  be 
applied  or  the  neck  of  the  bladder  massaged  through  the  rectum. 
Excessive  irritability  of  the  bladder,  whether  caused  by  urinary  infec- 
tion or  of  nervous  origin,  demands  the  administration  of  vesical  seda- 
tives, injections  of  normal  saline  or  boric  acid  solution,  and  rest  in 
bed.  Sometimes  a  stone  is  discovered  in  the  bladder,  and  its  removal 
is  always  attended  by  cure. 

When  remote  conditions,  such  as  enlarged  tonsils  and  adenoids, 
are  treated,  the  results  are  not  nearly  as  good,  with  the  possible 
exception  of  hypothyroidism,  when  the  administration  of  thyroid 
extract  usually  effects  a  cure.  Having  remedied  the  cause  of  enuresis, 
the  habit  must  usually  be  overcome  before  improvement  sets  in.  One 
must  consider  that  such  a  child  is  usually  neurotic,  and  that,  instead 
of  harsh  measures  or  punishments,  it  needs  soothing  but  firm  treat- 
ment. It  should  have  the  advantage  of  a  change  of  climate  to  seashore 
or  country,  and  be  put  on  a  good  nutritious  diet  to  build  up  the 
physical  condition  which  in  most  cases  is  greatly  impaired.  Quiet 
is  especially  necessary,  the  nervous  tension  of  present-day  school  life 
being  a  hindrance  to  treatment. 


538  DISEASES  OF   THE  GEXITO-URINARY  SYSTEM 

Certain  routine  iDstruetions  slioiild  he  ^'i\'en  in  each  ease.  Tlie 
child  should  he  made  to  urinate  hefore  going  to  hed,  and  he  awakened 
late  in  the  e\'ening  and  put  on  the  toilet.  The  foot  of  the  hed  should 
be  elevated,  and  the  child  kept  from  lying  on  its  back  by  means  of 
a  towel  tied  around  the  waist  and  knotted  in  the  back.  Sometimes  a 
change  from  one  bed  to  another  will  induce  temporary  relief.  The 
diet  should  be  bland  and  non-irritating;  coffee,  tea,  and  spices  must 
be  prohibited.  The  evening  meal  should  be  a  light  one,  and  no  fluids 
be  taken  after  4  p.m.  The  bowels  should  be  kept  regular  throughout 
the  treatment,  and  no  food  or  medication  given  that  will  irritate  the 
urinary  tract  or  produce  constipation. 

If  the  child  is  anemic  or  chlorotic  tonics,  such  as  arsenic  and  cod- 
liver  oil,  are  indicated  and  may  be  given  with  a  few  grains  of  sodium 
bromide  added  to  each  dose.  The  two  most  valuable  drugs  in  the 
treatment  of  enuresis  are  belladomia  and  strycluiine.  Belladonna  owes 
its  effectiveness  to  its  sedative  action  on  the  muscular  wall  of  the 
bladder;  it  should  be  administered  in  increasing  doses  until  the  physi- 
ological effect  is  obtained.  A  child  of  tliree  may  take  1  drop  of  the 
tincture,  three  times  a  day,  increasing  it  1  drop  daily  mitil  there  is 
dryness  of  the  throat  and  a  flushed  skin.  It  may  then  be  reduced  1 
drop  a  day  mitil  the  flushing  ceases,  and  continued  at  this  dose  for 
several  weeks.  If  there  is  no  appreciable  improvement  after  such 
administration  of  belladonna,  it  is  useless  to  -continue  it. 

Tincture  of  nux  vomica  is  mdicated  where  the  sphincter  of  the 
bladder  is  weak;  this  accounts  for  the  particularly  good  results 
obtained  by  the  use  of  this  drug  when  dimiial  and  nocturnal  enuresis 
are  combined.  The  dose  is  2  drops  three  times  a  day,  to  a  child  of 
three  years.  This  dose  may  be  cautiously  increased.  Ergot  has 
been  given  for  its  tonic  effect  on  the  bladder  wall,  but  it  is  the  con- 
sensus of  opinion  that  it  is  useless  when  belladonna  and  strvchnine 
fail. 

Cathelin's  treatment  is  worthy  of  trial  and  is  justifiable  when  milder 
measures  fail,  for  80  per  cent,  of  cures  are  recorded  where  it  has  been 
carried  out.  The  patient  is  placed  in  Sim's  lateral  posture,  and  the 
coccygeal  spine  located.  A  lumbar  puncture  needle  is  introduced  in 
the  middle  of  a  line  joming  the  coccygeal  cornua,  and  is  passed  directly 
upward,  care  bemg  taken  not  to  perforate  the  meninges.  From  5 
to  25  c.c.  of  normal  saline  solution,  at  body  temperature,  are  then 
slowly  injected.  The  process  is  almost  painless,  and  the  child  may  be 
sent  home  as  soon  as  it  is  done.  In  some  cases  a  second  injection  is 
necessary  ten  days  later. 

NEPHRITIS. 

Nephritis  is  not  uncommon  in  children  at  any  period  from  birth  to 
puberty,  and  may  occur  in  any  of  the  types  seen  in  adults.  Our 
classification  of  the  various  forms  of  nephritis  is  still  unsatisfactory, 
the  term  nephritis,  itself,  being  restricted  to  non-suppurative  inflam- 
mation of  the  kidney,  thus  making  it  necessary  to  use  a  ciualifying 


NEPHRITIS  539 

adjective  when  a  sui)pnrative  process  is  spoken  of.  Just  as  in  adults, 
l)oth  acute  and  chronic  ne])hritis  occur  in  childhood,  although  the 
latter  is  rare;  but,  in  addition  to  this  classification,  nephritis,  as  seen 
by  the  pediatrician,  may  well  be  classified  etiologically.  During 
infancy  one  may  differentiate  a  distinct  form  of  nepliritis  due  to 
coigenital  syphilis,  another  arising  from  gastro-intestinal  disturb- 
ances, a  variety  of  other  types  produced  by  various  infections  and 
intoxications,  as  well  as  a  type  which  resembles  the  contracted  kidney 
of  adult  life.  In  older  children  one  meets  with  nephritis  which  is 
usually  secondary,  and  in  which  acute  infectious  diseases  play  an 
important  part  as  primary  factors.  Thus,  we  may  divide  these 
nephritides  into  the  scarlatinal  and  diphtheritic  types,  and  those  due 
to  other  infections  and  intoxications  of  unknown  or  doubtful  nature. 

Acute  Congestion  of  the  Kidneys. — Acute  renal  congestion,  or  renal 
hyperemia,  is  much  more  common  in  children  than  in  adults  because 
in  the  child  it  is  so  easily  induced.  The  usual  cause  is  an  acute  infec- 
tious disease;  but  it  may  be  the  result  of  severe  digestive  disturbance, 
high  fever,  irritating  drugs  used  indiscriminately  or  taken  acciden- 
tally, or  of  exposure  to  cold. 

Pathology. — The  kidney  of  active  congestion  is  slightly  enlarged, 
swollen,  and,  after  the  capsule  has  been  removed,  appears  brown  or 
mottled.  On  section  the  cortex  is  wider  and  darker  than  in  health,  the 
bloodvessels  are  engorged,  and  the  cells  are  the  seat  of  cloudy  swellmg. 

Symptoms. — There  are  rarely  any  symptoms  except  a  change  in 
the  urine,  which  may  show  albumin,  with  a  few  hyaline  and  granular 
casts.  It  is  usually  high  colored,  of  high  specific  gravity,  and  scanty 
in  amount — sometimes  so  scanty  as  to  constitute  partial  suppression; 
yet  rapid  improvement  is  possible  with  no  trace  of  kidney  lesion 
remaining.  The  duration  of  the  attack  varies,  recovery  taking  place 
promptly  after  removal  of  the  cause. 

Treatment. — The  child  whose  urine  shows  evidence  of  acute  conges- 
tion of  the  kidneys  should  be  kept  in  bed  on  a  milk  diet  until  recovery 
has  taken  place.  It  should  drink  plenty  of  water  in  order  to  dilute  the 
toxins  circulating  in  the  blood  and  acting  upon  the  kidneys,  and 
increased  excretion  of  toxins  through  the  skin  and  bowels  may  be 
promoted  by  means  of  vapor  or  hot  baths  and  saline  cathartics.  Hot 
applications  over  the  kidney  region  act  as  mild  counter-irritants, 
and  relieve  the  feeling  of  discomfort  usually  present  in  the  loins  in 
this  condition. 

Nephritis  in  Infancy. — Xo  accurate  estimate  can  be  made  as  to  the 
frequency  with  which  neplu-itis  occurs  during  infancy  because  of  the 
difficulty  in  detecting  its  presence;  this,  however,  makes  it  appear 
reasonable  that  it  is  more  common  than  observations  lead  us  to  sup- 
pose. Several  factors  increase  the  difficulty  of  diagnosing  nephi-itis 
in  infants,  not  the  least  of  which  is  the  problem  of  collecting  the  urine 
in  a  suspected  case;  but  far  more  puzzling  is  the  frequent  occurrence 
of  nephritis  without  edema,  also  the  possibility  of  both  edema  and 
albuminuria  appearing  in  uifancy  with  no  demonstrable  nephritis. 


540  DISEASES  OF   THE  GENITO-URINARY  SYSTEM 

Etiology. — Primary  nephritis  in  infants  is  rare,  although  it  is  probable 
that  many  mild  cases  escape  detection.  Syphilis  and  gastro-intestinal 
disorders  account  for  most  of  the  cases,  but  one  cannot  ignore  its 
association  with  bronchopneumonia,  erysipelas,  and  extensive  skin 
affections,  when  it  may  be  considered  as  a  complication.  It  is  also 
a  complication  of  the  acute  infectious  diseases  when,  by  chance,  they 
occur  in  infants.  Occasionally  a  case  is  reported  of  nephritis  asso- 
ciated with  scurvy. 

Pathology. — The  syphilitic  kidney  exhibits  microscopically  an  inter- 
stitial nephritis,  but  is  normal  to  the  naked  eye,  since  there  is  no 
actual  fibrosis,  although  the  glomeruli  and  tubules  may  be  imper- 
fectly developed  owmg  to  the  syphilitic  process.  It  is  only  excep- 
tionally that  the  preponderance  of  changes  in  the  parenchyma  justifies 
the  diagnosis  of  parenchymatous  nephritis,  rather  than  the  interstitial 
variety. 

The  kidneys  of  an  infant  with  nephritis  of  gastro-intestinal  origin 
are  also  normal  macroscopically;  but,  m  contradistinction  to  the 
changes  in  syphilitic  nephritis,  there  is  usually  fatty  degeneration  of  the 
epithelium  of  the  convoluted  tubules,  but  no  change  in  the  glomeruli. 

Symptoms. — Acute  nephritis,  whether  of  syphilitic  or  gastro-intes- 
tmal  origin  is,  as  a  rule,  latent.  The  infant  with  hereditary  s.yphilis 
whose  kidneys  are  affected  rarely  shows  any  symptoms.  The  urine 
contains  albumin  and  casts,  but  is  not  diminished  in  quantity,  and, 
when  tested  for  blood,  is  negative.  Uremia  practically  never  occurs, 
and  edema  rarely  is  seeu.  It  is  not  fatal,  and  its  severity  bears  no 
relation  to  the  degree  of  the  other  syphilitic  manifestations,  although 
it  readily  clears  up  under  treatment  which  corrects  the  disease  else- 
where in  the  body. 

The  course  of  the  disease  is  acute,  and  the  symptoms  latent.  The 
nervous  symptoms  are  very  infrequent  in  nephritis  of  gastro-mtestinal 
origin  and  in  syphilitic  nephritis;  but  it  is  believed  by  some  authorities 
that  the  symptoms  referable  to  the  nervous  system  which  appear  in 
the  course  of  fatal  gastro-enteritis  associated  with  nephritis  may  be 
uremic  in  character.  The  urine  also  shows  more  decided  changes, 
and,  in  addition  to  albumin  and  casts,  it  sometimes  contams  blood. 

It  is,  apparently,  only  in  the  severe  primary  acute  nephritis  of 
infancy  that  symptoms  and  signs  are  the  predominating  features 
of  the  disease.  Here  the  disease  is  usually  a  diffuse  nephritis,  but  the 
invoh'ement  of  the  parenchyma  is  secondary  to  the  interstitial  lesions 
which  are  more  pronounced.  The  sjTnptoms  are  high  but  iiTegular 
fever,  vomiting,  diarrhea,  dyspnea  in  severe  cases,  anemia,  and 
nervous  manifestations.  The  lu-ine  may  or  may  not  contain  albumin 
at  the  onset;  but,  together  with  casts,  it  appears  at  some  stage  of  the 
disease  in  every  case.  Although  there  is  no  edema,  this  form  of  neph- 
ritis is  very  grave,  and  a  mortality  of  over  70  per  cent,  is  recorded. 
As  a  rule,  the  nephritis  associated  with  scurvy  is  latent,  and  albumin 
and  casts  in  the  urine  may  persist  for  months  after  the  total  disap- 
pearance of  the  scorbutic  condition. 


NEPHRITIS  541 

Prognosis. — From  the  preceding  description  of  the  various  forms 
of  nephritis  which  occur  in  infancy  it  is  evident  that,  with  the  excep- 
tion of  the  severe,  acute,  primary  type,  the  prognosis  as  to  Ufe  is  good, 
the  syphihtic  form  offering,  perhaps,  the  best  ultimate  chance  for 
recovery.  Some  chnicians  beheve  that  the  acute  interstitial  nephritis 
of  infancy  is  of  chronic  nature,  and  results  in  a  contracted  kidney, 
such  as  is  observed  in  adult  life. 

Acute  Diffuse  Nephritis. — Under  this  title  will  be  included  acute 
parenchymatous  nephritis,  acute  exudative  nephritis,  acute  desqua- 
mative nephritis,  glomerular  nephritis,  acute  tubular  nephritis,  and 
acute  interstitial  nephritis. 

Etiology. — From  an  etiological  stand-point,  the  term  acute  nephritis 
may  well  embrace  all  the  various  forms  of  this  disease  enumerated 
above,  since  they  all  result  from  inflammatory  changes  produced  by 
the  action  of  toxins  and  bacteria.  It  is  true,  however,  that  the  action 
of  toxins  alone  is  limited  to  degeneration  of  the  epithelial  cells  of  the 
kidney,  while  bacterial  invasion  of  the  kidney  results,  not  only  in 
degenerative  processes  in  the  epithelium,  but  also  in  infiltration  of 
the  kidney  with  newly  formed  cells  which  are  probably  the  precursors 
of  the  fibrosis  which  follows.  Infection  of  the  kidney  is  quite  fre- 
quently predisposed  to  by  a  degenerative  condition  of  the  organ 
induced  by  the  action  of  toxins;  but,  in  a  few  cases,  usually  severe  in 
type,  the  bacterial  infection  occurs  with  no  antecedent  changes  in 
the  kidney  structure  whatsoever,  as  typified  in  the  nephritis  of  the 
first  week  of  scai'let  fever  or  diphtheria. 

There  can  be  no  doubt  that  scarlet  fever  is  the  most  common  cause 
of  nephritis  in  childhood.  Why  the  kidneys  should  be  so  peculiarly 
vulnerable  in  this  disease  is  not  kuown;  but  the  frequency  with  which 
scarlet  fever  is  accompanied  by  acute  inflammation  of  the  kidneys  is 
known  the  world  over,  even  to  the  laity.  The  attack  may  have  been 
mild,  and  the  symptoms  may  have  entirely  disappeared;  yet  nephritis 
occurs  which  is  suggestive  of  the  operation  of  a  variety  of  causes; 
and,  although  the  toxin  must  be  regarded  as  the  primary  factor,  one 
cannot  overlook  the  possible  added  effect  of  exposure  to  cold,  errors 
in  diet,  constipation,  and  too  short  a  period  of  rest  in  bed. 

The  toxins  produced  in  scarlet  fever  have  a  particularly  selective 
action  for  the  glomeruli.  Acute  nephritis  is  an  earlier  complication 
in  diphtheria  than  in  scarlet  fever,  but  by  no  means  as  common;  and 
the  toxins  of  diphtheria  injure  both  glomeruli  and  tubules.  The 
proper  use  of  diphtheria  antitoxin  is  largely  responsible  for  the  com- 
parative rarit}'  of  nephritis  as  a  complication  of  that  disease.  As 
a  complication  of  the  other  common  infections  of  childhood,  nephritis 
is  also  comparatively  rare;  but  it  occasionally  accompanies  chicken- 
pox,  epidemic  cerebrospinal  meningitis,  measles,  German  measles, 
mumps,  and  whooping-cough. 

Other  diseases  of  childhood  which  are  sometimes  accompanied  or 
followed  by  nephritis  are  pneumonia,  influenza,  rheumatic  fever, 
tonsillitis,  typhoid  fever,  smallpox,  tuberculosis,  and,  in  the  tropics, 


542  DISEASES  OF   THE  GEN  I  TO-URINARY  SYSTEM 

malarial  fever.  With  septicemia  and  pyemia  due  to  the  streptococcus, 
staphylococcus,  pneumococcus,  or  gonococcus,  febrile  albuminuria 
is  the  rule,  although  nephritis  is  not  uncommon. 

Certain  extraneous  substances,  if  ingested,  are  capable  of  producing 
nephritis  and  in  their  action  resemble  the  toxins  of  scarlet  fever  and 
diphtheria;  for  instance,  arsenic,  can tharides,  and  snake  venom  affect 
chiefly  the  glomeruli;  while  bichloride  of  mercury,  uranium  nitrate, 
and  potassium  and  ammonium  chromate  affect  chiefly  the  tubular 
epithelium,  attacking  the  glomeruli  but  slightly,  if  at  all.  Other 
exogenous  toxins  which  cause  nephritis,  but  whose  selective  action 
is  as  yet  not  clearly  defined,  are  turpentine,  carbolic  acid,  potassium 
chlorate,  salicylic  acid,  oxalic  acid,  the  mineral  acids,  alcohol,  chloro- 
form, phosphorus,  and  lead. 

In  addition  to  these  toxic  substances  which  are  introduced  from 
without  the  body,  we  cannot  fail  to  recognize  the  importance  of 
various  toxins  produced  within  the  body;  for  instance,  from  the 
gastro-intestinal  tract  in  digestive  disorders,  these  being  most  marked 
during  infancy,  also  in  jaundice,  in  diabetes,  and  in  children  of  gouty 
ancestry.  The  importance  of  cold  as  an  etiological  factor  in  the 
causation  of  nephritis  has  been  greatly  overestimated,  as  in  all  prob- 
ability it  does  nothing  more  than  favor  the  action  of  pathogenic  bac- 
teria, thus  differing  in  no  respect  from  its  influence  on  inflammation 
of  other  organs  of  the  bod^'. 

Of  the  predisposing  causes  of  nephritis,  age  and  heredity  are  the  only 
ones  which  influence  this  disease  in  childhood.  There  can  be  no 
question  that  the  tendency  to  nephritis  is  sometimes  transmitted; 
but  this  is  infrequent  because,  in  these  cases,  nephritis  is  chronic, 
whereas  most  of  the  cases  of  nephritis  seen  in  children  are  of  the 
acute  type. 

Pathology. — In  acute  nephritis  both  kidneys  are  enlarged,  are  softer 
than  usual,  and  ha^•e  a  more  rounded  appearance.  The  color  varies; 
but,  after  removing  the  capsule  which  strips  readily,  the  convex  sur- 
face presents  a  pale,  grayish,  mottled  appearance,  with  light  red  and 
quite  dark  red  spots  caused  by  hemorrhage  and  the  congestion  of  the 
stellate  veins.  Upon  incising  the  capsule  the  kidney  substance  may 
bulge  through,  and,  upon  sectioning,  the  cortex  is  found  to  be  much 
swollen  and  grayish-yellow  or  light  red  in  color.  The  pyramids  seem 
unusually  red  in  contrast  with  the  pale  cortex,  its  yellow  areas  or 
streaks  marking  the  degenerated  tubular  epithelium. 

Microscopic  examination  shows  involvement  of  the  glomeruli, 
tubular  epithelium,  and"  interstitial  tissue,  the  extent  to  which  each 
is  involved  depending  somewhat  upon  the  cause  of  the  nephi'itis.  The 
glomeruli  are  swollen  and  hyperemic,  and  the  capillaries  are  tense 
with  blood  that  may  be  in  thrombus  form.  Bowman's  capsular  space 
is  filled  with  exudate  and  debris  which  cause  pressure  upon  the  vessels 
of  the  tuft  and  upon  the  tubules,  markedly  disturbing  the  function 
of  the  glomeruli,  and  accounting  in  some  measure  for  the  albuminuria, 
oligm-ia,  and,  perhaps,  the  increased  blood-pressure  of  nephritis. 


NEPHRITIS  543 

The  tubular  epithelium  undergoes  cloudy  swelling  and  fatty  degen- 
eration, and  may  desquamate;  and  the  tubules  themselves  contain 
red  blood  cells,  leukocytes,  desquamated  erdothelium,  and  casts. 
In  cases  of  short  duration,  inflammatory  edema,  round-cell  infiltra- 
tion, and  hemorrhagic  areas  are  found  in  the  interstitial  tissue;  and, 
if  the  attack  has  been  prolonged,  there  may  be  an  increase  in  connec- 
tive tissue.  There  is  an  exudative  type  of  acute  diffuse  nephritis  which 
is  observed  in  infants  and  young  children  and  is  characterized  by 
large  accumulations  of  leukocytes,  serum,  and  red  blood  cells  in  the 
glomeruli  and  tubules,  with  either  marked  or  but  little  change  in 
the  parenchyma  and  interstitial  tissue. 

Syro.ptoms, — Acute  nephritis  may  manifest  itself  in  two  ways: 
either  by  an  abrupt,  frank  onset  with  edema,  pallor,  headache,  gastric 
disturbance,  and  conspicuous  urinary  changes,  typified  by  scarlatinal 
nephritis;  or  by  another  type  of  the  disease  in  which — though  the 
onset  may  be  sudden — there  are  no  frank  symptoms,  and  only  by 
most  careful  study  of  the  urine  can  any  changes  in  its  quantity  and 
microscopic  or  chemical  properties  be  detected.  This  latter  form  is 
characteristic  of  the  acute  nephritis  which  occurs  during  the  course  of 
typhoid  fever  or  pneumonia. 

There  are  three  symptoms  of  acute  nephritis  in  children  which  are 
fairly  constant — edema,  uremic  manifestations,  and  urinary  changes. 
The  edema  may  be  extreme  and  develop  rapidly,  although  it  some- 
times varies  so  greatly  that  the  child  may  be  entirely  free  from  it  for 
weeks  and  even  months  at  a  time.  It  is  rather  firm  at  the  onset, 
and  is  most  noticeable  in  the  face  in  the  morning,  causing  puffiness, 
swollen  eyelids,  watery  eyes,  and  a  pasty  expressionless  look  which 
is  characteristic.  A  similar  puffiness  of  the  fingers,  ankles,  the  back 
of  the  hands,  and  scrotum  occurs;  later  on  there  is  infiltration  of  the 
subcutaneous  tissues  over  the  back  and  abdomen.  The  increase  in 
weight  is  sometimes  40  per  cent,  of  the  previous  body  weight. 

As  a  rule,  the  urine  is  markedly  diminished  in  quantity,  and  sup- 
pression is  not  uncommon.  Albumin  and  casts  are  constantly  present, 
and  a  trace  of  blood  may  be  found  occasionally.  The  color  becomes 
very  dark;  the  specific  gravity  is  normal  or  slightly  raised.  One  of 
the  earliest  signs  of  recovery  is  an  increased  output  of  urine. 

The  usual  temperature  range  is  from  100°  to  103°  F.,  but  in  very 
severe  attacks  it  may  reach  105°  F.  As  a  rule,  the  high  temperature 
does  not  long  persist,  and  a  continuous  elevation  of  temperature  is 
to  be  regarded  rather  unfavorably.  Headache,  backache,  extreme 
restlessness,  and  stupor  are  due  to  toxemia.  In  severe  cases  there  may 
be  uremic  convulsions  preceded  by  nausea,  vomiting,  deficient  excre- 
tion of  urea,  and  a  urinous  odor  to  the  breath  and  perspiration. 

A  fulminating  type  of  nephritis  may  occur  in  which  the  onset  is 
very  abrupt,  accompanied  by  high  temperature,  scanty  urine,  rich 
in  albumin,  casts,  and  blood.  The  pulse  is  full,  of  high  tension,  and 
there  is  severe  pain  in  the  lumbar,  region.  Nausea,  vomiting, "and 
diarrhea,  with  extreme  restlessness  passing  into  stupor,  signify  the 


5U  DISEASES  OF   THE  GEN  I  TO-URINARY  SYSTEM 

early  approach  of  uremia;  and,  unless  diuretic  measures  are  prompt 
in  relieving  it,  death  rapidly  ensues.  Children,  however,  bear  extreme 
oligiu-ia  and  suppression  of  urine  relatively  better  than  do  adults, 
and  cases  have  been  reported  where  suppression  for  three,  five,  or  ten 
days  was  followed  by  recovery. 

Duration. — The  duration  of  an  ordinary  attack  of  acute  nephritis 
is  usually  from  one  to  three  weeks.  It  depends  largely  upon  the 
severity  of  the  particular  case,  and  may  be  prolonged  greatly  beyond 
its  usual  course;  but,  m  view  of  the  fact  that  recovery  may  take  place 
after  six  months  or  a  year,  one  month  seems  but  a  short  time. 

Complications. — The  most  frequent  complications  of  acute  nephritis 
are  endocarditis,  pericarditis,  pleurisy,  bronchitis,  bronchopneumonia, 
and  lobar  pneumonia.  Erysipelas,  meningitis,  and  edema  of  the  glottis 
are  but  rarely  observed. 

Diagnosis. — The  only  possible  way  by  Avhich  a  ph\'sician  can  accu- 
rately diagnose  the  cases  of  acute  nepln-itis  in  children  which  come 
under  his -care  is  to  carefully  examine  the  urme  in  all  cases,  and  make 
daily  urinalyses  of  his  scarlet  fever  patients.  He  must  carefully  rule 
out  cyclic  albuminuria,  febrile  albuminuria,  congestion  of  the  kidney, 
infarcts,  amyloid  disease,  tumors,  and  calculi  before  attributing 
urinary  changes  to  acute  nephritis.  While  it  is  desirable,  if  possible, 
to  recognize  acute  nephritis  by  m*malysis  before  clmical  signs  and 
symptoms  appear,  the  disease  is  occasionally  not  suspected  until  the 
characteristic  appearance  of  swelling  about  the  eyes  and  ankles,  with, 
perhaps,  fever,  vomiting,  and  headache,  leaves  no  doubt  as  to  the 
diagnosis. 

Prognosis. — Acute  nephritis  is  always  a  serious  disease,  yet  the 
tendency  in  scarlatinal  nephritis  is  to  recovery,  and  the  prognosis 
in  severe  acute  nephritis  is  good  if  the  case  is  properly  managed  from 
the  onset  until  at  least  six  months  after  convalescence  begins.  If 
not  properly  treated,  a  mild  acute  nephritis  may  pass  into  a  chronic 
nephritis  with  doubtful  prospects  as  to  final  cure.  Acute  nephritis 
in  infants  and  young  children  often  terminates  fatally,  and  in  a  variety 
of  ways;  uremia  is  the  most  common  cause  of  death  in  older  children, 
but  in  the  younger  ones  complications,  especially  of  the  respiratory 
tract,  may  lead  to  a  fatal  termination. 

Cln-onic  nephritis  was  formerly  thought  to  be  an  unusual  sequel 
of  acute  nephritis  in  childhood,  but  we  have  been  misled,  perhaps, 
by  the  relatively  long  period  of  apparent  health  which  may  elapse 
between  the  initial  attack  and  subsequent  ones;  therefore  the  least 
we  can  say  is  that  the  kidneys  are  left  in  a  condition  which  renders 
them  susceptible  to  futiue  attacks.  Of  the  various  aids  to  prognosis 
in  a  given  case  of  acute  nephritis,  the  presence  or  absence  of  uremic 
manifestations  and  the  amount  of  urine  voided  daily  are,  perhaps, 
the  most  reliable,  although  each  case  must  be  studied  and  judged  bv 
itself. 

Treatment. — .Judicious  treatment  of  any  acute  infection  is  the  best 
prophylaxis  of  acute  nepkritis  in  childhood;  therefore,  in  those  dis- 


NEPHRITIS  545 

eases  which  are  especially  liable  to  cause  nephritis  precautions  as  to 
diet,  clothing,  catharsis,  the  use  of  drugs,  and  proper  exercise,  should 
extend  well  into  convalescence.  Since  it  is  the  irritation  of  the  kidneys 
by  toxins  eliminated  during  the  course  of  infectious  diseases  which 
causes  nephritis,  an  attempt  must  be  made  by  free  catharsis  and 
stimulation  of  the  excretory  function  of  the  skin  to  eliminate  these 
excrementitious  substances  when  present  in  the  urine.  The  urine 
may  be  rendered  less  irritating  if  we  increase  the  daily  output  by 
restricting  the  patient  to  milk  or  buttermilk,  whey,  koumiss,  or 
junket,  with,  possibly,  cereals  and  gruels  at  meal  time,  and  fruit 
between  meals. 

The  value  of  diphtheria  antitoxin  as  a  prophylactic  against  nephri- 
tis has  already  been  emphasized;  but  the  abuse  of  other  therapeutic 
agents,  chief  of  which  is  the  too  free  administration  of  certain  drugs, 
may  induce  nephritis.  Alcohol  and  urotropin  are,  perhaps,  foremost 
in  the  list  of  harmful  drugs;  extreme  caution  must  be  observed  also 
in  the  use  of  salicylic  acid,  potassium  chlorate,  phenol,  mercury,  and 
other  recognized  renal  irritants.  The  effect  of  exposure  to  cold  in  the 
development  of  nephritis  during  the  acute  infections  has  probably 
been  overestimated;  but  prolonged  exposure  to  cold,  and  especially  to 
dampness  and  cold,  should,  of  course,  be  avoided. 

The  active  treatment  of  acute  nephritis  should  be  undertaken  with 
three  objects  m  view;  viz.,  the  removal  of  the  cause;  the  reestablish- 
ment  of  kidney  secretion  and  the  securing  of  rest  for  these  organs  by 
increasing  elimination  through  the  skin  and  bowels;  and  the  treat- 
ment of  symptoms  and  complications.  Removal  of  the  cause  of 
acute  nephritis  may  be  brought  about  by  the  prompt  and  efficacious 
treatment  of  an  existing  infectious  disease,  or  by  discontinuing  the 
use  of  such  drugs  as  are  known  to  irritate  the  kidneys.  In  order  to 
lessen  the  work  of  the  now  crippled  kidneys,  free  saline  catharsis 
should.be  induced  by  the  use  of  magnesium  sulphate  in  2-dram  doses 
daily  to  a  child  of  five  years,  and  the  skin  kept  acting  freely  by  means 
of  frequent  sponges  and  warm  baths,  and  not  allowing  the  temperature 
of  the  sick  room  to  fall  below  70°  F. 

The  diet  should  consist  of  food  which  will  not  aggravate  the  inflam- 
mation of  the  kidneys.  For  a  child  of  five  years,  21  ounces  of  milk 
daily,  given  7  ounces  at  a  time  with  a  little  cereal,  and  supplemented 
by  some  apple  sauce  or  jelly,  with  stale  bread  or  zweibach  between 
meals,  meets  this  requirement  and  is  amply  sustaining.  This  diet 
should  be  insisted  upon  for  a  month  after  the  first  trace  of  albumin 
makes  its  appearance  in  the  urine,  and  the  only  indication  for  increas- 
ing it  is  the  advent  of  anemia  or  steady  loss  of  weight.  Cognizant 
of  the  fact  that  in  individuals  with  apparently  healthy  kidneys  the 
ingestion  of  sodium  chloride  is  followed  by  chloride  retention  which 
equals  that  in  mild  nephritis,  the  value  of  a  salt-free  diet  is  apt  to  be 
overestimated;  but  in  all  forms  of  nephritis  associated  with  renal 
edema  the  restriction  of  sodium  chloride  to  1  or  2  grams  (15  to  30 
grains)  daily  for  a  child  of  five  years  is  desirable,  and  only  when  edema 
35 


546  DISEASES  OF   THE  GENl TO-URINARY  SYSTEM 

is  marked  should  a  salt-free  diet  be  advised;  even  in  this  case  it  should 
not  be  maintained  for  a  long  period.  The  proteins  ingested  should 
never  exceed  an  ounce  a  day,  and  a  diet  of  fats  and  carbohydrates 
leaves  less  residue  in  the  shape  of  solids  for  elimination  through  the 
kidneys.  Fruits,  such  as  oranges,  grape  fruit,  apples,  either  baked 
or  made  into  sauce,  and  lemonade  form  an  acceptable  addition  to 
the  diet,  and  are  not  injurious,  in  some  instances  acting  as  diuretics. 
Rest  in  bed  is  imperative,  and  should  be  insisted  upon  until  albumin 
and  casts  have  permanently  disappeared  from  the  urine. 

Change  of  climate  is  only  to  be  considered  in  subacute  and  chronic 
cases,  for  the  danger  of  overexertion  or  exposure  to  cold  makes  travel- 
ing undesirable;  the  child  is  much  better  off  at  home  under  proper 
treatment. 

Severe  cases  of  nephritis  marked  by  high  fever,  partial  suppression 
of  urine,  and  intense  edema,  require  more  active  and  radical  proced- 
ures. The  hot  pack  and  Vapor  bath  should  now  be  resorted  to  for 
increased  stimulation  of  the  skin,  and  an  effort  be  made  to  increase 
diuresis  by  the  application  of  hot  flaxseed  or  mustard  poultices  to  the 
loins,  or  by  dry  cupping.  Colonic  flushings,  using  a  pint  of  normal 
saline  solution  at  110°  F.  for  a  child  of  five  years,  will  often  increase 
the  kidney  action,  and  should  be  repeated  every  six  hours  until  effec- 
tive. Tincture  of  aconite,  in  1-drop  doses  for  a  child  of  five  years, 
may  be  repeated  every  two  hours  until  there  is  slight  diaphoresis; 
and  nitroglycerin,  ^ii)  of  a  grain  may  be  given  hourly  until  the  high- 
tension  pulse  is  relieved. 

If  uremia  supervene,  the  convulsions  can  sometimes  be  controlled 
or  prevented  by  the  hypodermic  administration  of  morphine,  2V  of 
a  grain  at  a  dose  for  a  child  of  five  years.  Venesection  is  advisable 
in  severe  attacks,  and  though  extremely  difficult  because  of  the 
collapsibility  of  the  veins  in  children,  at  least  a  half-pint  of  blood 
should  be  withdrawn  and  a  pint  of  normal  salt  solution  injected. 
The  withdrawal  of  a  test-tubeful  of  spinal  fluid  by  lumbar  puncture 
gives  relief  in  some  cases,  and  may  be  tried  in  extremity.  If  the  heart 
grows  weak,  tincture  of  strophanthus  should  be  administered  in  3-drop 
doses,  every  three  hours,  to  a  child  of  five  years.  Other  symptoms 
may  necessitate  special  treatment.  If  the  edema  be  severe,  paracen- 
tesis of  the  abdomen  or  pleura  and  puncture  of  the  legs  is  sometimes 
required.    Edema  of  the  larynx  may  necessitate  tracheotomy. 

Convalescence  is  tedious;  the  anemia  so  often  present  is  improved 
by  the  administration  of  Basham's  mixture  (liquor  ferri  et  ammonii 
acetatis),  in  1-dram  doses  to  a  child  of  five  years.  Sudden  exposure 
to  cold  should  be  carefully  guarded  against,  and  exercise  taken  very 
moderately.  The  diet  should  be  cautiously  increased,  avoiding  much 
nitrogenous  food.  With  convalescence  fairly  well  established,  or  if 
the  disease  shows  a  tendency  to  become  subacute,  it  is  perhaps  advis- 
able to  send  the  child  to  a  warm  equable  climate;  the  winters, 
especially,  should,  if  possible,  be  spent  in  Florida  or  Southern  Cali- 
fornia. 


NEPHRITIS  547 

Chronic  Nephritis. — Chronic  nephritis  is  one  of  the  rare  diseases 
of  childhood.  It  is  ahiiost  unknown  in  infancy,  and  practically  never 
observed  before  the  third  year,  most'  cases  occurring  between  the 
fifth  year  and  puberty.  There  are  three  forms  of  chronic  nephritis 
in  children  which  conform  more  or  less  to  the  adult  types;  i.  e.,  chronic 
parenchymatous  nephritis  (chronic  diffuse  n  on -indurative  nephritis); 
chronic  interstitial  nephritis  (chronic  diffuse  indurative  nephritis) ; 
and  the  waxy  or  lardaceous  kidney.  The  chronic  parenchymatous 
type  may  assume  the  characteristics  of  the  chronic  interstitial  variety 
as  the  disease  progresses.  Amyloid  disease,  which  causes  the  waxy 
kidney,  is  a  degenerative  process  which  may  be  engrafted  on  a  chronic 
nephritis  of  childhood. 

Etiology. — The  direct  relation  of  chronic  nephritis  to  acute  nephritis 
in  childhood  is  definite,  which  is  in  sharp  contrast  with  the  obscure 
connection  between  these  two  diseases  in  adult  life.  Most  cases  follow 
acute  scarlatinal  nephritis  and,  less  frequently,  the  other  acute  infec- 
tions. Amyloid  disease  of  the  kidney  is  most  apt  to  be  the  sequel  of 
syphilis,  tuberculosis,  chronic  suppuration,  rachitis,  or  chronic  malaria. 
Hereditary  syphilis  may  account  for  that  very  rare  form  of  chronic 
nephritis  in  childhood — the  interstitial  variety — in  which  a  gouty 
ancestry,  tuberculosis,  alcoholism,  and  chronic  valvular  heart  disease 
are  supposed  to  be  predisposing  factors.  The  occurrence  of  chronic 
nephritis  in  more  than  one  child  in  a  family  also  suggests  the  possible 
influence  of  heredity.  All  the  other  etiological  factors  of  acute  neph- 
ritis may  be  considered  capable  of  indirectly  producing  a  chronic 
nephritis. 

Pathology. — The  lesions  produced  in  the  kidneys  by  the  three 
types  of  chronic  nephritis  w^hich  occur  in  childhood  do  not  differ 
essentially  from  those  observed  in  adult  life.  The  kidney  in  chronic 
parenchymatous  nephritis  is  enlarged,  pale,  of  decreased  consistence, 
and  has  a  smooth  surface;  the  capsule  is  not  adherent.  On  section 
the  cortex  is  found  to  be  w^der  than  normal  and  yellowish-white 
in  color,  on  account  of  which  it  is  called  the  "large  white 
kidney." 

The  microscope  shows  the  convoluted  tubules  to  be  thickened  and 
dilated,  the  epithelium  undergoing  granular  and  fatty  degeneration 
and  exfoliation,  but  only  exceptionally  are  the  tubules  atrophied. 
The  glomeruli  may  be  either  compressed  and  atrophied  or  may  show- 
hyaline  changes,  swelling,  cellular  proliferation,  and  desquamation. 
The  large  red  kidney — the  result  of  multiple  hemorrhages  in  the  cortex 
— and  the  small  white  kidney,  which  is  the  same  size  or  even  smaller 
than  the  normal  organ,  are  rarer  pathological  forms  which  the  kidney 
may  assume  in  chronic  parenchymatous  nephritis. 

In  chronic  interstitial  nephritis  the  kidneys  are  usually  much 
atrophied,  and  appear  drawn  or  shrunken,  hence  the  synonym  "con- 
tracted kidney."  They  are  red  or  reddish-gray  in  color,  and  the  cortex 
is  much  thinner  than  usual.  The  capsule  is  firmly  adherent  and  strips 
off  with  difficulty,  exposing  a  coarse,  granular  kidney  surface.     The 


548  DISEASES  OF   THE  GEX I  TO-URINARY  SYSTEM 

most  characteristic  microscopic  change  noted  is  the  marked  increase 
in  fibrous  tissue  distributed  irregularly  tlii'oughout  the  kidney 
structure. 

Other  changes  may  be  practically  the  same  as  those  observed  in 
the  chronic  parenchymatous  type.  The  tubules  in  one  part  of  the 
kidney  may  be  completely  atrophied,  and  in  another  they  are  dilated, 
forming  cysts.  If  no  chronic  congestion  of  the  kidney  has  preceded 
the  inflammation,  the  glomeruli  are  atrophied;  but  if  chronic  conges- 
tion has  taken  place  they  may  be  large,  the  capillaries  dilated,  and 
the  walls  showing  hyaline  degeneration.  Cardiovascular  lesions  are 
commonly  present,  and  include  atheroma  of  the  arteries  and  cardiac 
hypertrophy.    Cirrhosis  of  the  liver  is  occasionally  seen. 

In  amyloid  disease  the  changes  are  not  confined  to  the  kidneys,  but 
these  organs  are  considerably  enlarged,  grayish  in  color,  and  of  putt>-- 
like  consistency.  The  lardaceous  material  is  most  abundant  along 
the  renal  vessels  and  in  the  vascular  tufts  of  the  glomeruli,  and  the 
kidney  substance  atrophies  as  the  amyloid  deposits  increase.  Other 
organs,  such  as  the  suprarenal  glands,  spleen,  liver,  and  intestinal 
villi  are  also  involved. 

Symptoms. — Chronic  Parenchymatous  Nephritis. — The  onset  of  this 
form  of  clu-onic  nepliritis  is  usually  an  exacerbation  of  an  acute  attack 
of  nephritis  which  in  some  cases  immediately  precedes  it,  while  in 
others  it  may  be  separated  from  it  by  months  or  even  years.  Rarely 
do  we  find  a  case  which  is  chronic  from  the  beginning,  with  insidious 
onset,  and  resembling  the  adult  type;  yet  the  undoubted  existence 
of  such  in  later  childhood  demands  recognition. 

The  physician  is  usually  consulted  on  account  of  indefinite  symp- 
toms, such  as  malaise,  anorexia,  pallor,  gastro-intestinal  distiubances, 
or  slight  puffiness  of  the  ankles  or  about  the  eyes.  There  may  be 
dropsical  accumulations  in  other  parts  of  the  body,  even  effusions 
into  the  pleura,  pericardium,  or  peritoneimi;  but  the  amount  of 
dropsical  fluid  varies  greatly,  bemg  markedly  increased  during  exacer- 
bations, and  diminished  or  entirely  absent  at  other  periods.  Anemia 
is  always  present,  vomiting  is  common,  and  various  nervous  phe- 
nomena, such  as  drowsiness,  insomnia,  fatigue,  headache,  and  neuralgia 
are  frequently  observed.  Unless  there  are  complications  there  is  no 
fever  in  chronic  nephritis. 

The  amount  of  urine  is  diminished,  but  the  daily  output  varies 
greatly  during  the  course  of  the  disease.  The  reaction  is  acid,  the 
specific  gravity  normal  or  a  little  above  normal,  and  on  standing  there 
is  an  abundant  sediment  of  urates,  casts,  epithelial  cells,  and  blood 
corpuscles.  Albumin  is  constantly  present,  and  greatly  increased 
during  exacerbations,  the  total  amomit  lost  during  the  day  reaching 
as  high  as  20  grams  (5  drams) .  The  number  of  casts  is  usually  in 
direct  proportion  to  the  amount  of  albumin  in  the  urine.  They  are 
hyalin,  granular,  epithelial,  and  fatty,  with  broad  outlines;  oil 
globules  may  be  perceived  upon  many  of  them.  Free  fat  droplets 
are  often  found;  but  red  and  white  corpuscles  are  not  abundant  in 


NEPHRITIS  549 

the  urine  of  chronic  parenchymatous  nephritis  except  during  acute 
exacerbations. 

Lardaceous  or  waxy  degeneration  of  the  kidneys  is  associated 
with  greater  ascites,  also  with  amyloid  deposits  in  the  liver,  spleen, 
and  intestinal  canal  which  cause  enlargement  of  these  organs,  and 
often  obstinate  diarrhea  which  renders  the  prognosis  grave.  The 
urine  is  pale  yellow  in  color,  of  low  specific  gravity,  and  contains 
hyalin  and  waxy  casts.  Albuminuria  and  polyuria  are  usually  present, 
but  there  is  rarely  blood  in  the  urine,  and  but  little  sediment  on 
standing.  Mild  cases  are  not  recognized  because,  instead  of  the 
typically  weak,  pale,  cachetic,  emaciated  child  with  muddy  com- 
plexion, the  patient  may  have  a  good  ruddy  complexion,  be  fairly 
strong  and  fat,  and  show  no  evidence  of  dropsy. 

The  duration  of  these  forms  of  renal  disease  depends  largely  upon 
the  surroundings  of  the  patient,  the  amount  of  renal  tissue  involved, 
and  the  treatment.  Pulmonary  edema  not  infrequently  brings  chronic 
parenchymatous  nephritis  to  a  fatal  termination,  and  in  both  of  these 
diseases  death  is  usually  due  to  pneumonia,  pericarditis,  pleurisy,  or 
endocarditis.  Uremia  is  uncommon  in  children;  when  it  does  occur, 
it  is  usually  associated  with  chronic  interstitial  nephritis. 

The  symptoms  of  chronic  interstitial  nephritis  seem  in  many  cases 
to  date  from  birth,  but  they  are  indefinite,  vague,  and  few  in  number. 
The  child  is  pale  and  delicate  from  infancy,  anemic,  and  usually 
stunted  in  growth;  but,  when  the  case  comes  under  observation, 
anemic  pallor  may  be  replaced  by  a  peculiar  dusky  flush,  due  to  capil- 
lary congestion.  Dropsy  is  rare.  The  blood-pressure,  high  with  hyper- 
trophy of  the  left  ventricle,  and  atheromatous  changes  in  the  arteries 
are  not  infrequent.  Nervous  disturbances  are  common,  and  include 
headache,  neuralgia,  albuminuric  retinitis,  retinal  hemorrhages,  and 
attacks  of  spasmodic  dyspnea;  toward  the  end  of  the  illness  convulsions 
and  cerebral  hemorrhage  may  also  occur.  The  urine  is  pale,  of  low 
specific  gravity,  increased  in  quantity,  and  voided  frequently  in  large 
amounts.  The  sediment  is  quite  scanty;  under  the  microscope  it 
is  found  to  be  composed  of  a  few  epithelial  cells,  a  few  hyaline  or 
granular  casts,  and  an  occasional  red  or  white  blood  corpuscle. 

Diagnosis. — In  the  early  stages  of  the  disease  when  few  symptoms 
appear,  chronic  nephritis  may  be  easily  overlooked  and  not  diag- 
nosed until  after  careful  urinalyses  have  been  made,  since  albumin 
and  casts  may  be  present  in  the  urine  for  quite  a  while  without 
the  appearance  of  any  other  symptoms  of  nephritis  than  anemia. 
Children  presenting  symptoms  such  as  convulsions,  persistent  or 
frequent  headaches,  or  cardiac  hypertrophy  with  high  arterial  ten- 
sion, and-  all  cases  of  general  malnutrition,  should  have  their  urine 
carefully  examined,  for  it  is  failure  to  examine  the  urine  of  children 
routinely  that  accounts  for  the  frequency  with  which  chronic  nephritis 
is  undiagnosed  in  childhood  unless  it  be  accompanied  by  frank  symp- 
toms, such  as  dropsy  with  scanty  urine.  If  the  urine  be  carefully 
examined,  functional  albummuria  is  the  onlv  condition  which  can 


550  DISEASES  OF   THE  GEN  I  TO-URINARY  SYSTEM 

possibly  need  to  be  differentiated  from  cliroiiic  nepliritis,  and  oriiaiiic 
renal  disease  can  be  excluded  only  after  repeated  and  thorough  lu'inary 
analyses. 

Prognosis. — One  who  expects  permanent  recovery  from  chronic 
"nephritis  will,  in  the  majority  of  cases,  be  disappointed.  Although 
these  patients  may  live  for  a  number  of  years  with  comparatively 
few  symptoms,  the  outlook,  as  to  ultimate  or  complete  recovery 
is  unfavorable.  The  prognosis,  also,  largely  depends  on  the  circum- 
stances of  the  parents;  for,  in  the  parenchymatous  type  particularly, 
life  can  be  prolonged  and  made  tolerable  for  years  if  the  child  can  be 
kept  midst  ideal  surroundings  in  an  equable  climate. 

Chronic  interstitial  nephritis  offers  the  least  favorable  prognosis; 
and  in  chronic  parenchymatous  nephritis,  or  cases  of  waxy  kidney, 
the  outlook  is  serious  when  there  is  a  persistently  increasing  amount 
of  urine  of  low  specific  gravity,  this  indicating  fibrotic  changes  in  the 
interstitial  tissue  and  Malpighian  tufts.  Other  unfavorable  signs  in 
chronic  nephritis  are  a  considerable  amount  of  dropsy,  valvular  disease 
of  the  heart  associated  with  nephritis,  and  a  greatly  diminished  output 
of  urea. 

Treatment. — The  principles  of  treatment  in  chronic  nephritis  are 
the  same  that  apply  in  the  acute  form.  The  child  should  be  carefully 
protected  from  any  influence  which  might  lead  to  an  exacerbation. 
To  this  end,  excessive  muscular  exertion,  exposure  to  the  acute  infec- 
tions, chilling,  drugs  that  irritate  the  kidney,  and  dietetic  errors 
should  be  avoided.  Since  outdoor  life  is  very  beneficial,  it  is  always 
advisable  to  reside  in  a  climate  where  the  winters  are  mild. 

Rest  in  bed  is  indicated  only  when  there  are  uremic  symptoms  or 
large  dropsical  accumulations.  While  the  child  is  in  bed,  the  diet 
should  be  the  same  as  that  prescribed  in  acute  nephritis.  If  it  be  up 
and  about,  the  list  may  include  fats,  carbohydrates,  well-cooked  green 
vegetables,  cereals,  fruits,  simple  desserts,  and  meat  three  times  a 
week.  Of  course,  food  or  drinks  known  to  be  renal  irritants  should 
be  avoided,  and  no  salt  should  be  added  to  any  food  except  what  is 
used  in  making  bread.  Water  or  milk  may  be  taken  as  beverages  in 
such  quantities  as  the  child  may  desire.  The  clothing  should  be  warm, 
and  w^oolens  may  be  worn  next  the  skin  all  the  year. 

Good  elimination  through  the  skin  and  bowels  is  important.  A 
daily  warm  bath  at  95°  to  100°  F.  is  of  great  benefit,  and  saline 
cathartics  are  advisable  to  keep  the  bowels  active,  especially  if  there 
is  much  edema.  Diuretics  also  are  indicated  when  edema  is  marked, 
and,  for  a  child  of  five  years,  1  dram  of  liquor  ferri  et  ammonii  acetatis, 
given  three  times  a  day,  has  the  additional  advantage  of  supplying 
iron  to  the  impoverished  blood.  In  severe  cases  cardiovascular 
stimulation  is  necessary. 

If  uremia  develops,  nitroglycerin  in  doses  of  yIji)  of  a  grain  may  be 
given  every  hour  to  lower  the  pulse  tension ;  even  venesection  may  be 
resorted  to.  Uremic  convulsions  may  require  the  hypodermic  injec- 
tion of  morphine  or  the  rectal  injection  of  chloral  hj^drate.     Active 


PERINEPHRITIS  551 

(liiirosis,  catharsis,  and  (]iai)h()rc'sis  should  l)e  iiuluced  by  the  measures 
outhned  in  the  discussion  of  the  treatment  of  acute  nephritis.  In 
cases  of  chronic  nephritis  which  fail  to  improxe  under  medical  treat- 
ment, and  in  which  the  specific  gravity  and  urea  output  are  constantly 
falling  and  uremia  impending,  Edebohls'  operation  of  splitting  the 
capsule  of  the  kidney,  while  not  curative,  should  be  resorted  to,  for 
it  sometimes  prolongs  life  and  adds  greatly  to  the  comfort  of  the 
patient. 

PERINEPHRITIS. 

Perinephritis  is  an  inflammation  of  the  tissues  surrounding  the 
kidney.  As  discussed  in  this  article,  the  term  perinephritis  includes 
inflammation  of  the  fibrous  capsule,  of  the  fatty  capsule  (epinephritis), 
and  of  the  retroperitoneal  fat  (paranephritis).  It  is  a  rare  condition 
in  children,  and  usually  terminates  in  abscess  formation,  although 
resolution  may  occur. 

Etiology. — Perinephritis  is  usually  a  secondary  affection,  arising 
either  from  metastasis,  the  infection  being  carried  by  the  blood  or 
lymph  stream,  or  by  direct  extension  from  a  neighboring  focus  of 
inflammation  or  suppuration,  such  as  a  psoas  abscess,  rectal  abscess, 
a  pyonephrosis,  or  an  appendicular  abscess.  The  primary'  form  is 
very  uncommon;  it  usually  develops  from  penetrating  w^ounds,  con- 
tusions, and  blows  in  the  region  of  the  kidney,  while  some  cases  may 
be  traced  to  a  sudden  strain,  the  lifting  of  heavy  weights,  or  even 
exposure  to  cold. 

Perinephritis,  as  met  with  in  the  acute  contagions,  is  believed  to 
be  due  to  secondary  pyogenic  infection  rather  than  to  the  primary 
disease.  Bacteria  are  always  the  immediate  cause,  and  the  various 
organisms  which  may  be  responsible  include  staphylococci,  strepto- 
cocci, and  pneumococci;  influenza,  colon,  typhoid,  and  tubercle  bacilli. 
In  many  cases  no  assignable  cause  can  be  discovered.  Right  and 
left  kidney  regions  are  affected  with  equal  frequency,  and  both  sexes 
are  equally  liable  to  the  disease. 

Pathology. — Abscess  formation  in  this  region  of  the  body  does  not 
differ  essentially  from  that  occurring  elsewhere.  Pus  may  burrow 
down  along  the  nreter  into  the  pelvis,  or  form  a  fluctuating  mass 
beneath  the  liver  or  spleen,  or  come  to  the  surface  posteriorly  near  the 
middle  of  the  intercostal  space,  or  point  just  above  Poupart's  ligament, 
or  discharge  its  contents  into  the  peritoneal  cavity,  vagina,  or  bladder. 

Symptoms. — In  primary  cases  the  onset  is  acute  with  fever,  and  the 
symptoms  are  referred  definitely  to  the  perinephric  region,  while 
secondary  perinephritis  is  apt  to  be  masked  by  symptoms  of  the  pri- 
mary disease,  and  may  not  be  recognized  until  a  soft,  fluctuating  tumor 
is  detected  on  bimanual  examination.  Pain  in  the  lumbar  region  with 
tenderness  on  pressure  is  usually  the  first  symptom,  and  may  be 
extremely  severe.  The  leg  is  held  semiflexed,  and  extension  is  very 
painful;  but  it  may  be  flexed  on  the  abdomen  without  discomfort. 
There  is  no  fixation  of  the  hip-joint.     Fever  is  variable  and  usually 


552  DISEASES  OF   THE  GEN  I  TO-URINARY  SYSTEM 

intermittent,  but  may  be  remittent,  or  continuous;  high,  low,  or 
absent;  and  in  acute  cases  is  preceded  by  a  chill. 

In  the  early  stages  there  is  no  local  swelling;  but  when  the  disease 
has  existed  for  some  time,  a  distinct  tumor  appears  in  the  back,  and 
by  palpation  a  smooth,  elastic  mass,  usually  fluctuating  and  generally 
fixed,  but  not  afi'ected  by  respiratory  movements,  can  be  made  out. 
Symptoms  referable  to  the  kidneys  are  present  only  when  the  inflam- 
mation involves  these  organs;  hence  the  urine  is,  as  a  rule,  normal, 
but  if  pyelitis  exists  it  contains  pus.  As  the  disease  progresses,  lame- 
ness and  deformity  become  prominent  symptoms.  There  is  deviation 
of  the  spine,  its  concaA'ity  being  toward  the  aft'ected  side;  pain  is  so 
increased  by  movements  of  the  limb  that  standing  or  walking  is 
rendered  impossible. 

Course. — The  duration  of  perinephritis,  primary  in  nature,  is  usually 
from  one  to  two  months,  as  recovery  generally  proceeds  rapidly  after 
evacuation  of  the  pus;  but  secondary  perinephritis  is  slow  and  insid- 
ious, and  may  last  six  months. 

Diagnosis. — Hip-joint  disease  is  so  closely  simulated  by  perinephritis 
that  careful  investigation  and  study  are  necessary  to  exclude  it,  espe- 
cially if  there  be  no  localized  abscess.  Acute  cases  of  perinephritis 
are,  of  course,  differentiated  by  the  rapidity  of  onset  and  the  general 
symptoms  of  an  acute  inflammatory  process;  even  those  cases  which 
are  subacute  or  chronic  in  character  run  a  different  course  and  are 
never  so  insidious  or  chronic  as  hip-joint  disease.  There  is  also  a 
marked  difference  in  the  limitation  of  motion  which  these  two  diseases 
cause;  for,  while  m  perinephritis  there  is  only  interference  with 
extension  of  the  thigh  on  the  affected  side,  in  hip-joint  disease  all 
movements  of  the  joint  are  restricted,  and  there  is  tenderness  in  the 
hip-joint  with  pain  which  is  frequently  referred  to  the  inner  side  of 
the  knee.  Psoas  abscess  from  Pott's  disease  may  cause  deformity 
and  lameness  and  thus  simulate  perinepln-itis ;  but  on  examination 
we  find  rigidity  of  the  spine,  angular  prominence,  and  other  evidences 
of  spinal  caries.  Early  diagnosis  of  perinephritis  is  always  difficult 
because  of  the  absence  of  tumor  and  the  masking  of  the  symptoms 
by  the  primary  disease.  In  doubtful  cases,  puncture  is  justifiable, 
and  the  .r-ray  may  sometimes  be  helpful. 

Prognosis. — In  primary  perinephritis  the  prognosis  is  good,  and  the 
majority  of  cases  in  children  terminate  in  recovery.  If  the  abscess 
points  externally  this  is  invariably  the  case,  especially  if  there  be 
early  surgical  interference.  The  only  condition  likely  to  prove  fatal 
is  rupture  of  the  abscess  into  the  peritoneal  cavity.  Occasionally  a 
persistent  fistula  results,  but,  as  a  rule,  recovery  is  complete. 

Treatment. — The  patient  should  be  put  to  bed  and  treated  symp- 
tomatically  until  the  diagnosis  is  made  with  certainty.  Pain  may 
be  relieved  by  hot  applications  and  poultices  to  the  affected  side,  but 
is  occasionally  so  severe  as  to  require  the  use  of  morphine  hypoder- 
matically.  When  the  diagnosis  is  established,  and  abscess  formation 
becomes  apparent,  but  one  procedure  is  indicated;  i.  e.,  the  abscess 


TUBERCULOSIS  OF   THE  KIDNEY  553 

must  be  freely  opened  and  drained,  and  all  pockets  of  pus  broken 
up  to  prevent  burrowing  and  subsequent  rupture  into  the  peritoneal 
cavity.  If  any  kidney  involvement  be  suspected,  this  organ  should 
be  palpated  or  even  incised,  and  nephrotomy  or  nephrectomy  be 
performed,  as  the  condition  demands. 

TUBERCULOSIS    OF    THE    KIDNEY. 

It  is  questionable  whether,  in  the  true  sense  of  the  w^ord,  there  are 
any  cases  of  primary  renal  tuberculosis;  and  in  children,  tuberculosis 
of  the  kidney,  without  clinical  evidence  of  the  disease  in  other  parts 
of  the  body,  is  extremely  rare.  In  general  tuberculosis  in  children  the 
kidneys  are  usually  involved,  but  the  knowledge  that  the  kidneys  are 
studded  with  miliary  tubercles  helps  little,  if  any,  in  the  subsequent 
treatment  of  miliary  tuberculosis,  and  this  phase  of  renal  tuberculosis 
is,  therefore,  of  little  importance.  When,  however,  tuberculosis  of 
the  kidney  occurs  with  no  demonstrable  active  lesions  elsewhere,  the 
so-called  ''primary  renal  tuberculosis,"  it  tends  to  remain  localized 
in  the  kidney,  and  prompt  and  proper  treatment  is  followed  by  brilliant 
results  in  a  large  proportion  of  cases. 

Etiology. — Miliary  tuberculosis  is  by  far  the  most  frequent  cause  of 
renal  tuberculosis  in  children;  the  infection  is  hematogenous,  and 
both  kidneys  are  involved.  Hematogenous  or  descending  infection 
may  arise  also  from  some  focus  of  tuberculosis  elsewhere  in  the  body, 
independent  of  general  tuberculosis.  Ascending  infection  from  other 
parts  of  the  genito-urinary  tract  is  extremely  rare;  but  infection 
by  continuity  from  some  adjoining  focus,  such  as  spinal  caries,  from 
tuberculosis  of  the  adrenals,  or  from  tuberculous  empyema  is  occa- 
sionally seen. 

Pathology. — In  general  tuberculosis  the  kidneys,  when  involved, 
show  many  small  tubercles  which  cover  the  surface  and  are  dissemi- 
nated throughout  the  substance  of  both  organs.  So-called  "primary 
tuberculosis"  is  usually  unilateral,  and  involves  first  the  cortex,  then 
the  mucous  membrane  of  the  pelvis  and  calices  to  the  pyramids,  so 
that,  in  advances  cases,  nearly  the  whole  organ  may  be  destroyed  and 
replaced  by  caseous  material.  Perinephric  inflammation  is  quite  com- 
mon in  renal  tuberculosis  as  the  result  of  direct  extension;  the  other 
kidney  may  become  involved  by  metastasis  or,  in  rare  instances, 
by  direct  extension  tia  the  bladder.  The  second  kidney  may  also 
show  signs  of  hypertrophy,  of  chronic  fibrosis,  or  of  amyloid  degen- 
eration. 

Symptoms. — In  acute  miliary  tuberculosis,  involvement  of  the 
kidneys  is  rarely  accompanied  by  any  symptoms,  and  in  the  primary 
type  of  renal  tuberculosis  the  symptoms,  particularly  at  the  onset, 
are  vague  and  indefinite.  There  may  be  pain  and  tenderness  in  the 
region  of  the  kidney  after  the  disease  has  become  established,  but 
the  first  symptom  is  usually  frequency  of  urination,  with  burning  and 
cramp-like  pains  which  increase  toward  the  end  of  micturition  and 


554  DISEASES  OF   THE  GEN  1  TO-URINARY  SYSTEM 

cease  wlien  tlie  l)la(l(ler  is  eni])ty.  lueontiiienee  is  oecasioiially  ])i'eseiit. 
In  iineoinplieated  cases  the  urine  is  acid  in  reaction,  and  contains 
albumin,  pns  cells,  blood,  and  tnbercle  bacilli.  Constitutional  dis- 
turbances develop  late,  and  include  fever  and  digestive  disturbances, 
while  toward  the  close  of  the  disease  emaciation,  anemia,  and  cachexia 
become  marked. 

Diagnosis. — The  diagnosis  is  made  by  the  symptoms  and  signs  of 
tuberculosis  elsewhere  in  the  body,  and  by  localized  manifestations 
of  kidney  disease,  such  as  pain  and  swelling  on  the  affected  side,  and 
is  confirmed  by  finding  the  tubercle  bacilli  in  uncontaminated  urine 
from  the  kidney. 

Prognosis. — The  prognosis  in  unilateral  renal  tuberculosis  which  is 
recognized  early  and  treated  by  nephrectomy  is  good;  but,  of  course, 
there  is  the  danger  of  the  operation.  In  bilateral  tuberculosis  of  the 
kidney  and  in  miliary  tuberculosis  the  outlook  is  unfavorable. 

Treatment. — Nephrectomy  offers  the  only  hope  of  real  cure.  Lesser 
operations,  such  as  nephrotomy  or  nephrostomy,  are  justifiable  only 
when  the  child's  condition  renders  nephrectomy  impossible.  Opera- 
tion should  be  followed  by  the  general  curative  measures  employed 
in  treating  tuberculosis,  such  as  fresh  air,  sunshine,  good  nutritious 
food,  and  suitable  climate. 

RENAL   CALCULI. 

Large  calculi  are  very  rarely  observed  in  children  under  four  years 
of  age,  but  m  infancy  there  is  a  marked  tendency  to  the  deposition 
of  fine  granules  of  m-ic  acid  in  the  pelvis  and  calices  of  the  kidney. 
These  deposits  have  been  found  in  more  than  one-half  of  the  infants 
w^ho  live  for  only  a  few  weeks,  and  are  for  the  most  part  composed 
of  uric  acid.  Lnder  ordinary  circumstances  these  crystals  are  dis- 
lodged during  early  infancy,  and  pass  out  in  the  urine.  The  affection 
is  not  accompanied  by  any  severe  symptoms,  unless  the  granules 
be  large,  and  should  pass  away  at  the  end  of  the  first  or  second  week. 
Xo  renal  lesions  follow,  so  that  there  is  no  danger  to  life,  and  the  free 
administration  of  water  will  soon  dissolve  the  deposits.  The  chemis- 
try of  larger  renal  calculi  and  the  mechanism  of  their  formation,  as 
well  as  the  symptoms,  are  the  same  as  in  the  adult. 

Etiology. — True  calculi  are  composed  of  uric  acid,  calcium  oxalate, 
and  phosphatic  concretions  of  which  bacteria  and  cellular  detritus 
usually  form  the  nucleus.  " 

Symptoms. — The  passage  of  small  uric  acid  granules  is  usually 
attended  with  no  symptoms  aside  from  their  appearance  on  the 
infant's  napkin,  which  is  sometimes  a  matter  of  great  concern  to,  the 
parents.  When,  however,  the  stone  is  of  such  size  that  it  passes  dow^n 
the  ureter  with  difficulty,  it  produces  paroxysms  of  excruciating  pain, 
which  is  apt  to  be  referred  to  the  umbilicus,  and  also  symptoms  not 
unlike  those  of  intestinal  colic.  Li  severe  cases  there  may  be  nausea, 
vomiting,   convulsions,   and   often  collapse,   until  the  stone  reaches 


TUMORS  OF  THE  KIDNEYS  555 

llic  l)lii(l(k'r,  wlicii  tlu'sc  syi)i])t()iiis  usiiall\'  cease.  If,  li«»\\c\'er,  the 
stone  becomes  iiiipaetecl  and  coini)letely  l)locks  the  ureter,  no  urine 
is  passed,  and  hydronephrosis  followed  by  jnonephrosis  or  j)yelonepli- 
rosis  quickly  develops.  The  older  the  child  the  more  closely  do  the 
symptoms  of  renal  calculi  adhere  to  the  adult  type;  pain  is  referred 
along  the  ureter  to  the  loins  and  thigh  of  the  affected  side,  and  may 
be  reflexly  felt  in  the  penis.  There  is  usually  hematuria.  The  testicle 
on  the  affected  side  may  be  dra\\TL  up  to  a  higher  level  than  its  fellow. 
The  passage  of  a  stone  through  the  urethra  will  cause  the  child  to 
run  about  in  pain,  grasping  the  penis,  and  if  the  stone  is  not  passed 
it  is  not  uncommon  after  an  attack  like  this  to  find  it  lodged  in  the 
urethra.  In  well-marked  cases  there  may  be  slight  fever,  indicating 
pyelitis,  with  pain  over  the  affected  kidney,  marked  tenderness  in 
this  region,  and  accompanying  pyuria.  Occasionally  renal  calculi 
are  found  at  autopsv  which  have  given  rise  to  no  svmptoms  during 
life. 

Diagnosis. — The  diagnosis  of  renal  calculus  is  sometimes  very 
difficult,  but  the  presence  of  any  of  the  foregoing  symptoms,  especially 
when  urinalysis  reveals  pus  or  blood,  is  strongly  suggestive.  The 
x-ray  is  of  actual  use  only  when  a  positive  result  is  obtained;  but 
should  be  resorted  to  in  every  case,  as  by  its  aid  w^e  frequently  dif- 
ferentiate renal  calculus  from  appendicitis.  In  infancy,  immediate 
diagnosis  from  intestinal  colic  is  impossible. 

Treatment. — Surgical  measures  are  warranted  only  when  the  presence 
of  a  large  stone  in  the  kidney  or  ureter  can  be  demonstrated,  and  is 
giving  rise  to  severe  symptoms.  In  milder  cases  symptomatic  treat- 
ment is  usually  sufficient.  It  consists  in  the  administration  of  plenty 
of  water,  and  the  correction  of  a  highly  acid  or  alkaline  urine  by  appro- 
priate medication.  Citric  or  acetic  acid  may  be  given  for  excessive 
phosphatic  concretions,  hexamethylenamin,  in  2-grain  doses  every 
four  hours  to  a  child  of  five  years,  if  the  deposits  be  of  uric  acid;  while 
oxalic  acid  crystals  call  for  tlie  internal  use  of  sodium  phosphate.  In 
some  cases  the  pain  may  be  relieved  by  the  application  of  heat  either 
as  a  poultice  or  hot  bath;  but  not  infrequently  the  hypodermic 
administration  of  morphine  with  atropine  is  necessary  to  relieve  pain. 
General  measures,  such  as  regulation  of  the  diet,  with  avoidance  of 
red  meat,  plenty  of  outdoor  exercise,  and  careful  attention  to  tlie 
bowels,  hasten  recovery,  and  are  prophylactic  as  regards  future  attacks. 

TUMORS    OF    THE   KIDNEYS. 

Benign  tumors  of  the  kidney  rarely  occur  during  childhood,  but 
malignant  growths  are  comparatively  frequent,  usually  of  develop- 
mental origin,  and  sarcomatous  in  type.  When  benign  tumors  do 
appear  in  children  they  generally  prove  to  be  adenomas,  fibromas, 
lipomas,  or  cysts,  and,  because  of  their  slow  growth,  they  cause  few 
if  any  symptoms,  remain  undiscovered,  and,  practically,  are  seen  only 
at  autopsy.    The  most  common  malignant  tumor  in  this  situation  is 


556  DISEASES  OF   THE  GEN  I  TO-URINARY  SYSTEM 

the  adenosarcoma,  which  is  almost  always  primary.  In  some  instances 
it  contains  several  varieties  of  epithelial,  adenomatous  and  connective- 
tissue  elements. 

Malignant  tumors  may  form  m  the  cortex  or  pelvis,  and  either 
invade  the  interior  of  the  kidney  or  project  from  its  external  surface. 
As  they  adhere  to  surrounding  tissues,  and  enlarge  rapidly,  they  may 
fill  the  whole  abdomen  in  a  relatively  short  time.  Malignant  growths 
are,  as  a  rule,  very  soft,  and  rarely  cystic;  they  frequently  show  a 
tendency  to  hemorrhage  within  the  substance  of  the  tumor. 

Ascites,  hydronephrosis,  and  thrombosis  of  the  vena  cava  may 
result  from  pressure,  but  general  peritonitis  rarely  develops,  although 
the  growth  may  attain  great  size,  not  uncommonly  weighing  from 
five  to  ten  pounds,  and,  in  rare  instances,  even  fifteen  pounds.  Metas- 
tasis is  common,  resulting  in  involvement  of  the  liver,  the  lungs,  the 
other  kidney,  the  mesenteric  nodes,  the  colon,  the  small  intestine, 
and  the  adrenals;  but,  curiously  enough,  secondary  growths  are  rarely 
found  in  the  bladder  or  ureters. 

Etiology. — Most  kidney  tumors  have  their  origin  in  embryonal 
tissue,  and  little  or  nothing  is  known  of  the  exciting,  causative  factors. 
The  typical  growth  found  in  the  kidney  during  childhood  is  peculiar 
to  children,  the  majority  of  cases  being  seen  before  the  fifth  year; 
instances  of  kidney  tumor  occurring  as  early  as  the  seventh  month 
of  intra-uterine  life  have  been  reported,  while  renal  growths  after  the 
ninth  year  are  exceedingly  rare.  The  left  kidney  is  more  frequently 
involved  than  the  right.    Both  sexes  are  equally  liable  to  the  disease. 

Symptom.s. — The  three  cardinal  symptoms  of  renal  tumor  are  hema- 
turia, pain,  and  tumor.  Constitutional  symptoms  appear  late,  and 
not  infrequently  the  first  suggestion  of  a  growth  is  the  appearance 
in  the  lumbar  region  of  a  mass  which  is  very  soft  with  smooth  or 
irregular  surface.  It  gives  rise  to  no  pain,  grows  rapidly  toward  the 
median  line  of  the  abdomen,  and  is  easily  palpable  under  the  large 
bowel.  At  this  time  it  is  so  symmetrical  that  its  relation  to  either 
kidney  may  be  impossible  to  ascertain.  In  some  instances,  careful 
physical  examination  is  necessary  to  exclude  enlargement  of  the  liver 
or  spleen  as  a  cause  of  the  distended  abdomen,  these  organs  being 
greatly  displaced  by  the  pressure  of  the  invading  mass  on  all  of  the 
abdominal  contents. 

Hematuria  is  a  common,  and  often  an  early  symptom  of  the  disease, 
indicating  an  infiltration  of  the  kidney  structure  by  the  growth,  for 
in  purely  extrarenal  and  intracapsular  tumors  bloody  micturition  is 
very  rare.  In  the  majority  of  cases,  the  blood  is  so  scant  as  to  be 
seen  only  microscopically,  although  at  times  the  hemorrhage  is  severe, 
and  occasionally  so  profuse  that  pain  is  produced  by  mechanical 
obstruction  of  the  ureter  by  clots. 

In  addition  there  may  be  paroxysmal  attacks  of  severe  colic,  although 
the  pain  is  usually  merely  a  dull  ache  producing  discomfort  and 
irritability  early  in  thedis  ease.  A  quickly  developing  cachexia  is 
always  noticeable;  it  is  unlike  that  of  anemia  or  tuberculosis,  and 


CONGENITAL  CYSTIC  KIDNEY  557 

is  so  characteristic  of  renal  tumor  as  to  be  regarded  as  one  of  the 
cardinal  symptoms  of  this  affection. 

Other  constitutional  signs  appear  late,  and  include  emaciation, 
loss  of  strength,  digestive  disturbances  from  pressure  on  the  stomach, 
dyspnea  from  pressiu-e  on  the  lungs,  and  edema  from  pressure  upon 
the  great  veins  of  the  abdomen. 

Diagnosis. — This  can  usually  be  made  with  comparative  certainty 
when  there  is  a  rapidly  enlarging  tumor  mass  in  the  kidney  area  with 
early  emaciation  and  cachexia,  and  it  is  substantiated  by  the  appear- 
ance of  blood  in  the  urine.  It  is  clinically  impossible  to  differentiate 
one  form  of  kidney  tumor  from  another;  but  in  view  of  the  fact  that 
early  operative  procedure  offers  the  patient  the  only  chance  for 
recovery,  the  diagnosis  of  any  growth  of  the  kidney  should  be  made 
at  the  onset  of  the  disease.  Kidney  tumor  should  always  be  con- 
sidered as  a  possible  cause  of  abdominal  enlargement  before  the  sixth 
year;  but  it  must  be  differentiated  from  tuberculosis  of  the  kidney, 
hydronephrosis,  pyonephrosis,  and  other  tumors  of  the  abdomen, 
such  as  enlarged  liver  or  spleen,  ovarian  cyst,  and  retroperitoneal 
sarcoma.  The  location  of  the  colon,  which  runs  along  and  above 
tumors  of  the  kidney,  and  the  position  of  the  swelling  near  the  costal 
margin  and  projecting  into  the  loin,  are  of  significance  in  differentiat- 
ing kidney  tumor  from  various  abdominal  tumors,  especially  enlarged 
spleen  and  liver. 

Prognosis. — The  prognosis  is  unfavorable,  as  this  disease  invariably 
ends  fatally  except  in  those  cases  where  an  early  diagnosis  is  cleverly 
made,  and  an  operation  performed  immediately.  Even  when  this 
is  done,  we  have  the  danger  of  death  from  shock  during  the  operation, 
or  from  metastasis  later. 

Treatment. — Medical  treatment  is  of  no  avail,  and  is  resorted  to 
only  symptomatically  in  cases  where  hope  of  cure  by  operation  has 
been  abardoned  because  of  the  extent  of  the  growth  or  the  appearance 
of  metastases.  Early  nephrectomy  is  justifiable  if,  by  any  chance, 
it  is  thought  the  child  can  withstand  the  operation.  A  few  recoveries 
have  resulted  where  this  has  been  done;  and,  even  if  the  chance  of 
cure  be  remote,  the  severity  of  the  symptoms  is  sometimes  greatly 
diminished  by  surgical  intervention. 

CONGENITAL    CYSTIC    KIDNEY. 

Congenital  cystic  disease  of  the  kidney  is  a  rare  affection.  It  usually 
affects  both  kidneys. 

Etiology. — The  etiology  of  these  congenital  cysts  has  not  yet  been 
clearly  demonstrated,  but  Shattuck,  after  systematic  histological  study, 
claims  that  the  condition  is  due  to  a  defect  in  development,  and  that 
the  mesonephros,  or  Wolffian  body,  becomes  attached  to  the  kidney 
or  melanephros,  and  the  cysts  are  formed  in  remnants  of  the  meso- 
nephros embedded  in  the  true  kidney. 

The  fact  that  other  congenital  malformations  frequently  coexist 


558  DISEASES  OF   THE  GEN  I  TO-URINARY  SYSTEM 

supports  this  theory  of  developmental  malformation.  The  earlier 
view  that  these  are  retention  cysts  due  to  prenatal  nephritis  has  been 
largely  abandoned.  Goodhart  and  Bateman  have  suggested  the  term 
'^ renal  adenoma,"  which  implies  that  these  cysts  are  new  growths. 

Pathology. — The  cysts  vary  in  size  from  the  diameter  of  an  ordinary 
uriniferous  tubule  to  that  of  a  pigeon's  egg,  and  are  most  numerous 
in  the  cortex.  In  some  cases  the  kidney  may  become  merely  a  collec- 
tion of  tiny  cysts,  none  larger  than  a  cherry,  supported  b}^  intervening 
atrophied  or  sclerotic  renal  tissue,  the  whole  mass  weighing  a  pound 
or  more.  In  other  cases  the  cysts  are  quite  large,  some  attaining  the 
size  of  a  child's  head,  and  they  may  coalesce. 

Kidney  tissue  may  be  wholly  absent  or,  at  least,  not  demonstrable 
in  the  fatal  cases  of  congenital  cystic  kidney  in  children;  but  in  the 
adult  some  renal  tissue  is  always  found.  If  only  one  kidney  is  involved, 
the  other  kidney  compensates  for  the  deficiency  of  renal  tissue  in  the 
diseased  organ. 


Fig.  54. — Congenital  cystic  kidney  in  an  infant  twenty-five  days  old. 


The  cysts  contain  a  clear  fluid,  which  is  composed  of  cholesterin, 
albumin,  blood  pigment,  fat,  triple  phosphates,  degenerating  cells, 
and,  in  rare  cases,  urea  or  uric  acid.  The  cyst  walls  are  usually  fibrous 
and  are  lined  with  flattened  or  columnar  epithelium.  There  is  a  dis- 
tinct connective-tissue  stroma,  and  here  and  there  between  the  cysts 
recognizable  glomeruli  and  urinary  tubules  with  saccular  dilatations. 
As  a  rule,  there  is  no  obstruction  of  the  ureters. 

Symptoms. — If  there  is  no  other  malformation  incompatible  with  life, 
and  the  kidneys  are  not  so  large  as  to  impede  labor,  the  child  may  be 
born  alive;  but  death  usually  occurs  during  delivery  or  soon  after 
birth.  In  many  cases  there  is  a  palpable  abdominal  tumor  which  may 
cause  pressure  symptoms.  Evidences  of  renal  insufficiency  are  also 
present. 

Uremic  symptoms  may  occur;  but  several  cases  have  been  reported 


Fig.  55. — Tubular  glands  resembling  sweat  glands. 


Fig.  56. — Cyst  wall  lined  by  columnar  epithelium. 


Fig.  57. — Cyst  wall  lined  by  flattened  epitheliur 


560 


DISEASES  OF   THE  GEN  I  TO-URINARY  SYSTEM 


of  children  who  lived  several  months  with  no  renal  symptoms.-    The 
duration  of    life    and   the  prominence   of    renal   symptoms   depend 


H-^' 


Fig.  58. — Congenital  cystic  kidney. 


entirely  on  the  amount  of  normal  kidney  tissue  present.     If,  as  in 
Fig.  54,  from  which  Figs.   55-59  were  made,  there  is   little   or  no 


Fig.  59. — Congenital  cystic  kidney  laid  open. 


normal  tissue  remaining  in  either  kidney,  the  baby  dies  within  a  few 
hours  after  birth.     If  only  a  small  amount  of  kidney  substance  is 


HYDRONEPHROSIS  561 

involved,  the  child  may  live  well  into  adult  life.  Where  life  is  pro- 
longed for  years,  hematuria  may  appear,  also  changes  in  the  heart  and 
arterial  system,  similar  to  those  in  interstitial  nephritis. 

Diagnosis. — The  diagnosis  of  congenital  cystic  disease  is  very 
difficult,  because  there  has  been  little  opportunity  to  study  the 
symptomatology.  The  fact  that  it  is  bilateral  is  an  aid  in  the 
differentiation  of  this  disease  from  hydronephrosis  and  malignancy. 

Prognosis. — The  prognosis  is  in  many  cases  unfavorable;  but  the 
consensus  of  opinion  seems  to  be  that  a  certain  number  of  cases  will 
live  well  into  middle  or  advanced  life,  in  spite  of  the  disease.  It  is 
also  claimed  that  the  affection  may  persist  for  years  without  producing 
any  serious  symptoms,  or  even  being  suspected. 

Treatment. — Treatment  by  drugs  offers  no  hope  of  cure,  and  surgical 
intervention  is  rarely  justifiable,  the  condition  being  usually  bilateral. 

HYDRONEPHROSIS. 

Hydronephrosis  may  be  either  congenital  or  acquired,  and  is  not 
a  rare  condition  in  children.  The  congenital  form  is  the  more  common. 
It  makes  its  appearance  during  infancy,  while  the  majority  of  cases 
of  acquired  hydronephrosis  de^'elop  late  in  childhood.  One  or  both 
kidneys  may  be  affected,  according  to  the  site  of  the  obstruction,  but 
double  or  bilateral  hydronephrosis  is  so  quickly  fatal  that  in  many 
instances  the  tumor  is  not  detected,  and  the  diagnosis  is  made  only 
at  autopsy.  Acquired  hydronephrosis  is  usually  unilateral;  therefore,' 
more  often  diagnosed  than  the  congenital  form,  which  is  frequently 
bilateral. 

Etiology. — Hydronephrosis  is  caused  by  an  obstruction  to  the  out- 
flow of  urine  somewhere  along  the  urinary  tract.  The  congenital 
form  results  from  stenosis  of  the  ureter  or  urethra,  imperforate  urethra, 
membranous  septa,  valves  or  cysts  which  impede  the  flow  of  urine, 
and  to  developmental  defects  of  the  ureter.  The  obstruction  is  gener- 
ally incomplete,  for  total  blocking  of  the  urinary  flow  tends  to  produce 
atrophy  of  the  kidney  rather  than  an  extreme  degree  of  hydronephrosis, 
although  in  all  types  of  hydronephrosis  the  kidney  usually  shows  a 
certain  amount  of  cirrhosis  and  dilatation. 

Acquired  hydronephrosis  is  most  frequently  seen  as  a  result  of  stop- 
page of  the  urinary  flow  by  renal  calculi;  but  it  may  also  be  caused 
by  inflammatory  stricture  of  the  ureter,  pressure  on  the  ureter  by 
neighboring  tumors,  kinking  of  the  ureter,  which  occurs  when  the 
kidney  is  movable,  and  by  a  tight  phimosis. 

In  addition  to  these  two  forms  of  hydronephrosis.  Holt  describes 
a  traumatic  hydronephrosis,  which  develops  after  the  early  symptoms 
of  trauma  have  subsided,  and  results  in  tumor  formation  two  weeks 
to  two  months  after  the  injury.  The  pathology  of  this  condition  is 
obscure,  but  it  presents  all  the  characteristics  of  hydronephrosis  aris- 
ing from  otlier  causes.  The  tumor  may  disappear  spontaneously, 
or  require  surgical  intervention  for  its  cure. 
36 


562  DISEASES  OF   THE  GEN  I  TO-URINARY  SYSTEM 

Pathology. — The  kidney  is  enlarged,  often  enormously,  and  loses 
its  reniform  shape.  As  the  urine  accumulates,  it  first  impinges  on  the 
pelvis  of  the  kidney  and  then,  by  pressure,  causes  dilatation  of  the  kid- 
ney with  atrophy  of  its  substance,  until  in  the  later  stages  the  organ 
is  represented  by  a  palpable  fluctuating  tumor.  This  enlargement  is 
much  slower  than  the  growth  of  the  kidney  tumor,  and  at  times  may 
considerably  decrease  in  size  by  the  occasional  escape  of  its  contents 
past  the  constriction  (intermittent  hydronephrosis). 

Some  authorities  claim  that  in  unilateral  hydronephrosis  there  is 
always  a  lesion  of  the  opposite  kidney,  usually  a  chronic  nephritis, 
induced  by  the  nephrotoxic  substances  which  are  formed  in  the  blood 
in  these  cases.  Infection  of  the  accumulation  of  urine  in  hydronephrosis 
results  in  pyonephrosis,  and  consequent  general  toxemia  or  septicemia. 
At  postmortem,  bilateral  hydronephrosis  has  been  found  to  have  caused 
dilatation  of  the  bladder  in  addition  to  distention  of  the  ureters  and 
kidneys. 

Symptoms. — The  chief  symptom  of  hydronephrosis  is  the  formation 
of  a  tumor  in  the  kidney  region.  When  the  accumulation  becomes 
very  large  its  pressure  may  produce  pain  and  local  tenderness,  which 
are  relieved  by  the  discharge  of  a  large  c^uantity  of  urine  of  low  specific 
gravity.  As  a  rule,  the  urine  is  scanty  in  amount,  and  may  not  reveal 
any  abnormal  condition  unless  infection  has  taken  place  in  the  hydro- 
nephi'otic  tumor.  Bilateral  hydronephrosis  usually  terminates  fatally 
in  such  a  short  time  that  no  characteristic  symptoms  appear. 

Prognosis. — Unilateral  hydronephrosis  offers  fair  chances  of  recovery, 
provided  that  the  fluid  does  not  become  infected,  and  the  other  kidney 
is  normal.  When  both  kidneys  are  involved,  the  case  is  invariably 
fatal. 

Treatment. — The  treatment  of  hydronephrosis,  whether  congenital 
or  acquired,  is  surgical.  Exploratory  puncture,  in- addition  to  giving 
temporary  relief,  aids  in  the  differentiation  of  hydronephrosis  from 
cysts,  new  growths,  and  tuberculosis  of  the  kidney.  The  ever-present 
danger  of  infection,  and  the  remote  possibility  of  rupture  of  the  sac, 
seem  to  justify  operation  even  in  the  absence  of  urgent  symptoms. 

If  a  stone  is  found,  or  some  other  obstruction  is  discovered  which 
'may  be  removed,  and  the  kidney  is  still  functionating,  nephrectomy 
is  by  no  means  indicated;  but  if  the  kidney  is  infected  or  practically 
destroyed,  and  the  obstruction  cannot  be  removed,  nephrectomy,  to 
say  the  least,  prevents  secondary  nephritis  in  the  other  kidney,  and 
in  many  cases  saves  the  life  of  the  child.  In  view  of  the  fact  that 
infection  of  the  accumulated  fluid  is  a  common  occurrence,  the 
administration  of  hexamethylenamin  should  be  kept  up  tliroughout 
the  whole  course  of  this  disease. 

MOVABLE    KIDNEY. 

Movable  or  floating  kidney  is  a  very  rare  condition  during  infancy 
and  childhood.    At  this  early  age  it  is  usually  a  result  of  some  develop- 


PYELITIS  563 

mental  defect,  such  as  an  elongated  pedicle  or  a  mesonephron,  but  has 
occasionally  been  caused  by  trauma  or  the  pressure  of  a  neighboring 
abdominal  tumor.  Of  the  few  cases  described  in  literature,  the  right 
kidney  was  in  children  the  one  most  frequently  affected.  Floating 
kidney  was  usually  associated  with  dyspepsia  and  dilatation  of  the 
stomach,  which  is  probabl}^  best  explained  by  the  close  relation  between 
the  solar  and  renal  plexuses. 

Other  symptoms  are  few  in  number.  They  may  consist  wholly 
in  a  slight  dragging-down  sensation  in  the  kidney  region,  with  some 
tenderness  and,  perhaps,  frequent  micturition.  In  many  patients 
there  may  be  no  symptoms  at  all,  so  that  the  condition  is  either  dis- 
covered by  accident  or  is  brought  to  the  physician's  attention  when 
the  pedicle  becomes  twisted  and  causes  paroxysms  of  pain  which  may 
simulate  intestinal  or  renal  colic,  or  vomiting  and  intense  prostration 
which  might  cause  one  to  mistake  it  for  appendicitis.  Hydronephrosis 
or  pyonephrosis  may  result  from  obstruction  of  the  ureter,  and  form 
a  tumor  in  the  loins. 

In  order  to  palpate  the  kidney  satisfactorily,  the  physician  should 
stand  on  the  side  of  the  patient  corresponding  to  the  kidney  he  wishes 
to  examine,  and  place  his  right  hand  under  the  left  loin,  or  his  left  hand 
under  the  right  loin,  and  allow  the  child  to  rest  upon  it.  The  opposite 
hand  should  make  gentle  pressure  upon  the  front  of  the  same  part, 
thus  attempting  to  press  the  kidney  between  the  two  hands.  If  mov- 
able, it  can  be  felt  to  slip  up  toward  the  liver,  or  down  toward  the  crest 
of  the  ilium.  Having  ascertained  that  the  kidney  is  movable,  and  if 
the  symptoms  are  very  mild,  no  treatment  is  necessary.  A  belt  may 
be  worn  if  discomfort  is  felt;  but  operation  is  only  justifiable  in  those 
cases  in  which  twisting  of  the  ureter  causes  severe  symptoms. 


DISEASES   OF   THE   BLADDER. 

PYELITIS. 

Pyelitis  is  in  reality  an  inflammation  of  the  mucous  membrane 
lining  the  pelvis  of  the  kidney;  but  so  often  is  the  bladder  involved 
as  well  as  the  kidney  that  the  terms  pyelocystitis,  pyelonephritis, 
and  pyelonephrosis  are,  perhaps,  more  descriptive  and  accurate  as 
applied  to  the  various  phases  of  this  affection. 

As  a  primary  disease,  pyelitis  is  probably  not  as  rare  as  is  supposed, 
and  were  urinalyses  made  routinely  in  the  case  of  infants,  its  existence 
would,  perhaps,  explain  some  of  the  cases  of  obscure  fever  at  this  early 
age.  Pyelitis  is  found  secondarily  in  older  children,  but  it  is  rare,  and 
its  manifestations  are  less  striking  and  typical  than  in  infants. 

Etiology. — The  Bacillus  coli  is  by  far  the  most  common  infecting 
organism  in  this  disease;  and  while,  in  a  fair  proportion  of  cases, 


564  DISEASES  OF   THE  GEN  I  TO-URINARY  SYSTEM 

staphylococci  and  streptococci  are  isolated,  other  organisms,  such  as 
the  tubercle  bacillus,  the  gonococcus,  the  Bacillus  typhosus,  and  the 
Bacillus  pyocyaneus,  are  much  less  frequently  met  with: 

The  bladder  is  probably  always  involved  primarily  in  infants,  and 
the  invading  organisms  pass  up  the  ureters  to  the  pelves  of  the  kidneys 
giving  rise,  in  the  majority  of  cases,  to  a  bilateral  affection  of  these 
organs,  but  rarely  causing  severe  inflammation  of  the  bladder.  This 
route  of  infection  probably  explains  satisfactorily  the  great  number  of 
little  girls  affected  by  this  disease,  and  its  relative  infrequency  in  little 
boys,  although  vulvovaginitis  accompanied  by  pyelitis  is  rarely  seen. 

The  numerous  cases  in  which  pyelitis  in  infancy  is  preceded  by  diar- 
rhea, constipation,  or  indigestion,  strongly  suggest  intestinal  disturb- 
ance as  a  preceding  factor,  and  it  is  quite  within  reason  to  assume  that, 
in  male  infants  especially,  the  colon  bacillus  may  gain  entrance  to  the 
bladder  directly  from  the  intestines.  The  majority  of  cases  of  pyelitis 
occur  in  children  under  two  years  of  age ;  after  the  fifth  year  it  is  rare, 
is  usually  caused  by  renal  calculi,  and  is  associated  with  tuberculosis 
or  tumors  of  the  kidne}'^,  or  is  secondary  to  scarlet  fever,  diphtheria, 
influenza,  or  typhoid  fever.  In  exceptional  instances  there  is  a  history 
of  trauma,  of  suppurative  processes  in  the  urethra  or  vagina,  or  of  the 
ingestion  of  such  drugs  as  turpentine,  cantharides,  or  carbolic  acid. 
Pyelitis  is  said  to  be  more  common  in  summer  than  in  winter,  probably 
owing  to  the  lowered  resistance  of  infants  at  this  season.  An  enum- 
eration of  the  etiological  factors  in  pyelitis  would  scarcely  be  complete 
without,  mentioning  the  hematogenous  and  lymphogenous  routes  by 
which  the  infection  may  ha^'e  been  carried  from  some  distant  part  of 
the  body. 

Symptoms. — The  most  characteristic  feature  of  pyelitis  in  infants 
is  the  presence  of  marked  constitutional  symptoms  with  little  or  no 
localized  evidence  of  the  disease;  while,  in  older  children,  the  local  symp- 
toms are  severe  and  the  constitutional  disturbances  mild.  In  infants, 
at  the  onset,  there  is  a  sudden  and  high  rise  in  temperature,  not  uncom- 
monly preceded  by  chills  and  rigors,  and  accompanied  by  other  evi- 
dences of  acute  infection,  such  as  vomiting,  diarrhea,  delirium,  or  a 
restless  drowsiness,  and  also  perhaps  a  stiffness  of  the  neck  and  twitch- 
ing of  the  limbs  which  suggest  meningitis.  There  is  usually  little  pain; 
but,  if  it  be  present,  it  so  closely  simulates  intestinal  colic,  as  to  be 
impossible  of  differentiation.  In  some  cases  the  abdominal  muscles 
on  one  or  both  sides  may  be  rigid.  These  symptoms  are  followed  in 
a  few  days  by  the  appearance  of  mucus  or  mucopus  in  the  urine,  which 
is  strongly  acid  Avhen  passed,  and,  examined  microscopically,  is  seen 
to  contain  numerous  bacilli  and  pus  cells  with  an  occasional  cast. 
Fever  is  usually  of  intermittent  type,  ranging  from  101°  to  105° 
or  106°  F.  for  a  week  or  several  days.  The  chills,  however,  are  seldom 
repeated,  although  the  urine  may  contain  pus  for  several  weeks. 

Older  children  frequently  complain  of  distinct  pain  in  the  abdomen 
with  tenderness  over  the  loin;  but,  as  a  rule,  the  disease  runs  a  subacute 
course,  with  anorexia,  nervous  irritability,  and  a  variable  temperature 


PYELITIS  565 

range.  The  urine  contains  pus  and  desquamated  epithelium  from  the 
various  parts  of  the  urinary  tract  involved.  If  cystitis  also  exists  to 
a  marked  degree,  dysuria  and  other  bladder  symptoms  are  present; 
and,  if  pyelonephritis  or  pyonephrosis  develop,  there  may  be  evidence 
of  tumor  formation  in  the  kidney  region.  Cautley  described  three 
types  of  pyelonephritis  in  children:  (1)  Acute,  with  rigors,  fever, 
lumbar  and  abdominal  pain,  and  sweating.  The  urine  is  unaffected 
for  two  or  three  days,  then  shows  pus  and  organisms.  Sometimes 
there  is  retention,  occasionally  blood.  (2)  Subacute,  with  unexplained 
fever,  anorexia,  malaise,  anemia,  and  wasting.  (3)  Chronic  relapsing, 
recurrent  attacks  with  fever,  headache,  vomiting,  malaise,  painful 
micturition,  and,  perhaps,  lumbar  pain  suggestive  of  stone. 

In  the  interim,  in  chronic  pyelitis,  which  is  usually  due  to  stone 
or  malformations,  pyuria  may  be  the  only  symptom  of  pyelitis  until 
suppurative  pyelonephritis  or  pyonephrosis  develops,  and  causes  the 
localized  symptoms  of  pain,  tenderness,  and  swelling.  Occasionally, 
perinephritis  develops  late  in  the  course  of  the  disease;  as  a  rule,  it 
rapidly  causes  an  abscess  from  which  the  pus  is  sometimes  discharged 
into  the  pelvis  of  the  kidney,  and  subsequently  voided  in  the  urine. 
Tuberculous  pyelitis,  when  observed,  is  usually  associated  with  general 
tuberculosis  and  is  evidenced  by  chronic  pyuria  and  the  presence  of 
tubercle  bacilli  in  the  urine. 

Diagnosis. — Although  the  diagnosis  of  pyelitis  in  infancy  hinges 
more  on  the  urinary  findings  than  on  any  other  signs  or  symptoms, 
the  significance  of  a  sudden  chill,  followed  by  high  fever  as  being  sug- 
gestive of  pyelitis,  cannot  be  too  greatly  emphasized.  Typhoid  fever, 
acute  intestinal  indigestion,  influenza,  and  especially  malaria,  are 
simulated  by  the  mode  of  onset  of  pyelitis;  but  careful  study  of  the 
temperature  range,  which  is  intermittent  with  distinct  afebrile  periods 
following  the  discharge  of  pus,  will  serve  to  exclude  all  of  these  diseases. 
Other  characteristic  symptoms  of  pyelitis  are  oliguria,  pyuria,  and  a 
variable  degree  of  pain  and  tenderness  over  the  kidneys.  The  relatively 
large  amount  of  pus  contained  therein  and  the  reaction  of  the  urine, 
which  is  acid,  will  exclude  inflammation  of  the  bladder  as  the  main 
source  of  the  infection,  while  the  severe  constitutional  symptoms,  with 
few  or  no  tube  casts  or  renal  epithelium  in  the  urine,  are  sufficient  to 
exclude  acute  nephritis.  Pneumonia,  meningitis,  and  otitis,  which 
should  always  be  considered  when  we  have  obscure  fever  in  infants, 
may  be  easily  excluded  by  an  accurate  history  and  the  absence  of  signs 
of  these  diseases  upon  thorough  examination.  Very  frequently  cys- 
titis coexists,  and  there  are  symptoms  and  signs  of  vesical  irritability; 
also,  with  the  development  of  pyelonephritis  and  pyonephrosis,  dis- 
tinct lumbar  pain  with,  perhaps,  tumor  formation  which  indicates 
that  one  is  dealing  with  more  than  simple  pyelitis. 

Prognosis. — When  pyelitis  remains  uncomplicated,  the  prognosis 
is  good,  and  the  duration  of  the  disease  depends  more  upon  the  time 
when  it  is  recognized  and  treated  than  upon  the  natiu'e  of  the  infection. 
In  pyelonephritis  and  pyonephrosis,  which  usually  develop  in  cases 


566  DISEASES  OF   THE  GEXITO-URINARY  SYSTEM 

of  pyelitis  secondary  to  acute  infections,  malformations,  or  tumors  of 
the  kidneys,  the  outlook  is  very  serious,  so  that  it  is  only  in  cases  of 
secondary  pyelitis  where  the  primary  cause  is  early  recognized,  and 
removed  before  renal  involvement  takes  place,  that  recovery  is  to  be 
hoped  for.  Relapses  are  not  infrequent,  and  may  occur  even  a  year 
after  the  initial  attack.  The  mortality  in  uncomplicated  pyelitis  is 
about  10  per  cent. 

Treatment. — The  treatment  of  pyelitis  varies  with  the  acuteness 
and  severity  of  the  attack,  and  there  can  be  no  doubt  that  many  infan- 
tile cases  pass  unnoticed  and  recover  spontaneously.  The  patient 
should  be  kept  at  rest  in  bed,  and  the  diet,  which  should  be  blaad  and 
non-irritating,  restricted  almost  wholly  to  milk.  Water  should  be  taken 
in  large  quantities,  and  this  may  be  encouraged  in  children  by  flavor- 
ing it  with  orange  or  lemon  juice.  The  reaction  of  the  urine  should 
be  neutralized.  For  this  purpose,  hexamethylenamin  is  largely  used 
when  hyperacidity  is  present,  one  grain  every  three  hours  being  the 
average  dose  for  an  infant  one  year  of  age,  and  correspondingly  larger 
doses  for  older  children. 

Citrate  of  potassium  in  massive  doses  is  exceedingly  beneficial,  and 
preferred  by  many  authorities  to  any  other  drug  for  the  treatment  of 
pyelitis.  As  much  as  one-half  or  even  one  dram  (four  grams)  may  be 
given  an  infant  one  year  old  and  upward  during  the  course  of  a  day  with 
no  decidedly  untoward  effects  aside  from  slight  depression  and  gastro- 
intestinal disturbance.  If  nausea,  depression,  and  low  temperature 
should  ensue,  sodium  bicarbonate,  in  lO-grain  doses  every  three 
hours,  may  be  given  to  an  infant  under  one  year  of  age  with  splendid 
results  and  no  harmful  effects. 

Pain  is  rarely  as  intense  as  in  renal  colic;  but,  if  severe,  may  be 
relieved  by  the  local  application  of  heat  or  cold,  or  by  the  administra- 
tion of  paregoric,  10  to  15  drops,  every  two  hours  until  relieved,  or 
until  four  doses  are  taken,  if  the  infant  be  a  year  old  or  less. 

In  chronic  cases,  the  bowels  should  be  watched  and  regular  move- 
ments promoted  by  adding  to  the  diet  enough  coarse  food  to  insure 
a  large  residue,  also  by  the  administration  of  mild  cathartics,  such  as 
compound  licorice  powder  or  salme  waters.  When  the  diet  is  greatly 
restricted,  as  in  acute  cases,  free  bowel  movements  should  be  obtained 
by  the  use  of  magnesium  sulphate  and  enemata. 

In  protracted  cases  of  pyelitis,  which  resist  all  other  treatment,  vac- 
cine therapy  should  be  instituted,  using  the  autogenous  vaccine  when- 
ever possible — for  response  to  this  line  of  treatment  may  avert  the 
development  of  pyelonephritis  or  pyonephrosis.  When  pyelitis  is 
secondary,  the  cause  should  be  removed  as  quickly  as  possible,  and  if 
pyonephrosis  develops,  surgical  intervention  is  indicated. 

Perinephritic  abscess  may  require  merely  incision  and  drainage; 
but  if  the  kidneys  be  involved,  as  in  suppurative  pyelonephritis  and 
pyonephrosis,  the  surgeon  must  decide  upon  either  nephrectomy, 
nephrotomy,  or  pyelotomy,  according  to  the  extent  of  renal  involve- 
ment and  the  functional  acti^-itv  of  the  other  kidnev. 


CYSTITIS  567 


CYSTITIS. 


Primary  cystitis  is  rare  during  infancy  and  childhood,  but  inflam- 
mation of  the  bladder  secondary  to  disease  elsewhere  in  the  genito- 
urinary tract  is  not  uncommon. 

Etiology. — The  organisms  most  frequently  found  are  the  gonococcus 
and  the  Bacillus  coli,  which  indicates  the  two  sources  of  infection — 
i.  e.,  the  external  genitalia  and  the  gastro-intestinal  tract.  Mechanical 
irritants,  such  as  calculi  and  gravel,  as  well  as  various  chemicals  and 
medicaments,  are  also  exciting  factors,  but  in  only  a  small  proportion 
of  the  cases.  Among  the  predisposing  causes  of  cystitis  are  excessive 
cold  or  heat,  strongly  ammoniacal  urine,  trauma,  or  any  condition 
which  lowers  the  tone  of  the  bladder  or  prevents  its  complete  emptying. 

Cystitis  is  much  more  common  in  girls  than  in  boys  owing  to  the  short 
urethra  in  females,  which  renders  extension  of  inflammation  by  this 
path  to  the  bladder  quite  natural.  Phimosis  and  a  narrow  urethral 
meatus  are  two  of  the  causes  of  cystitis  in  boys,  and,  as  a  rule,  the 
affection  when  due  to  either  of  these  conditions  is  very  severe.  In 
rare  instances,  tuberculosis  or  tumors  of  the  bladder  may  be  the  cause; 
in  some  cases,  inflammation  of  the  bladder  may  develop  during  the 
course  of  typhoid  fever,  although  bacteriuria  may  exist  indefinitely 
without  giving  rise  to  appreciable  bladder  lesion. 

Symptoms. — The  characteristic  symptom  of  cystitis  is  pollakiuria 
accompanied  by  vesical  spasm  which  causes  great  pain;  but  in  mild 
cases  in  which  there  is  no  pain,  the  unduly  frequent  passage  of  urine 
is  often  attributed  to  nervousness,  and  the  cystitis  is  overlooked. 
In  severe  cases  there  are  pain  and  tenderness  over  the  pubes  and  in 
the  perineum,  high  fever,  constitutional  disturbance,  and  even  convul- 
sions. The  urine  is  voided  a  little  at  a  time;  it  contains  epithelium, 
pus,  mucus,  many  bacteria,  and  a  trace  of  albumin.  It  is  of  a  reddish 
color,  alkaline  or  slightly  acid  in  reaction,  and  may  show  the  presence 
of  blood,  especially  if  the  cystitis  is  caused  by  calculi.  In  chronic 
forms  of  cystitis  the  symptoms  are  less  acute  and  usually  exist  unrecog- 
nized for  an  indefinite  period  until,  for  some  reason,  the  urine  is  exam- 
ined. If,  however,  a  vesical  calculus  be  the  cause  of  chronic  cystitis 
the  symptoms  are  more  severe,  and  although  the  pain  may  not  be  as 
great  as  in  the  acute  form,  pollakiuria  frequently  becomes  so  aggravated 
that  the  urine  appears  to  be  voided  continuously.  The  urine  presents 
the  same  characteristics  as  in  the  acute  form,  and  the  constant  drib- 
bling often  gives  rise  to  irritation  and  inflammation  of  the  genitalia 
and  adjacent  skin. 

Prognosis. — The  prognosis  in  simple  acute  cystitis  is  favorable,  and 
prompt  recovery  may  be  expected  after  removal  of  the  cause  and 
appropriate  treatment.  Chronic  cystitis  may  be  secondary  to  some 
primary  condition,  such  as  disease  of  the  kidney,  tumor,  or  tubercu- 
losis of  the  bladder,  and  in  these  cases  is  very  resistant  to  treatment. 

Treatment. — The  child  with  cystitis  should  be  put  to  bed  and  the 
diet  almost  wholly  restricted  to  liquids,  milk  being,  perhaps,  the  best 


568  DISEASES  OF   THE  GENITO-URINARY  SYSTEM 

form  of  nourishment.  The  child  should  be  encouraged  to  drink  a  large 
amount  of  water,  but  other  beverages,  such  as  tea  and  coffee,  should 
be  prohibited.  Potassium  citrate  in  massive  doses  has  proven,  in  my 
experience,  to  be  the  one  drug  jxtr  excellence  in  cystitis,  and  as  much 
as  1  dram  (4  grams)  has  been  administered  to  an  infant  a  year  old. 
The  child  should  take  enough  of  the  drug  to  keep  the  urine  slightly 
alkaline  or,  at  least,  neutral  in  reaction  until  the  pyuria  has  ceased. 

Urinary  antiseptics  are  also  indicated  in  cystitis,  the  best  results 
being  obtained  by  the  use  of  salol  or  hexamethylenamin  in  from  2- 
to  5-grain  doses,  three  times  a  day,  according  to  the  age  of  the  child. 
To  relieve  the  severe  pain  caused  by  vesical  spasm,  atropine  sulphate 
may  be  given  in  from  YiyiJi)  to  i^-^i,-  of  a  grain  doses,  three  times  a 
day,  according  to  the  tolerance  of  the  child.  If  this  is  not  efficacious, 
a  suppositor.y  of  opium  and  belladonna  should  be  inserted  in  the  rec- 
tum, and  hot  compresses  applied  over  the  bladder.  Unless  the  cystitis 
is  very  severe  or  shows  a  tendency  to  become  chronic,  irrigation  of 
the  bladder  is  not  advisable. 

Comparatively  few  cases  of  cystitis  become  chronic  during  child- 
hood, but  when  this  happens  they  are  very  stubborn  and  require  rad- 
ical measures  and  close  supervision  to  control  them  Daily  irrigation 
of  the  bladder  with  a  1  per  cent,  boric  acid  solution,  or  a  1  to  5000 
solution  of  either  silver  nitrate  or  potassium  permanganate,  should 
be  continued  for  a  week,  after  which  the  number  of  irrigations  should 
be  diminished  each  week  until  recovery  ensues,  although  it  is  sometimes 
a  good  plan  to  use  a  little  stronger  solution  at  each  irrigation. 

As  yet,  the  exact  value  of  autogenous  vaccines  in  cystitis  has  not 
been  definitely  established,  and  although  satisfactory  results  have 
been  claimed  by  some  observers,  my  own  experience  has  not  led  me 
to  use  them  except  as  a  last  resort  in  protracted  cases,  which  have  not 
responded  to  other  lines  of  treatment. 

VESICAL    SPASM. 

Spasm  of  the  bladder  occurs  most  frequently  in  the  early  years  of 
childhood.  When  observed  immediately  after  birth  it  is  due  to  uric 
acid  infarctions,  and  later  is  often  caused  by  an  excess  of  uric  acid 
in  the  urine.  It  is  a  characteristic  symptom  of  cystitis  and  vesical 
calculus,  and  may  be  the  result  of  blood-clots,  excessive  phosphatic 
deposits,  or  renal  gravel  which  obstructs  the  urinary  flow.  Occasion- 
ally, sudden  chilling  of  the  lower  abdomen  or  trauma  in  the  region  of 
the  bladder  is  followed  by  vesical  spasm,  and  in  rare  instances,  it  is 
seen  in  association  with  hysteria,  priapism,  and  masturbation.  The 
symptoms  are  chiefly  local,  and  indicati^^e  of  great  pain  and  difficulty 
in  urinating.  In  very  young  children  the  pain  may  simulate  intestinal 
colic;  but  the  absence  of  any  signs  or  symptoms  of  gastro-intestinal 
disturbance,  and  the  distended  bladder  which  abdominal  palpation 
reveals,  readily  establish  the  source  of  pain.  Urination  is  frequent, 
but  the  amount  of  urine  passed  each  time  is  small. 


VESICAL  CALCULI  569 

Treatment. — Removal  of  the  cause  is  essential  to  permanent  relief 
of  the  conditon.  Distention  of  the  bladder  frequently  necessitates 
catheterization;  but  hot  baths  or  hot  compresses  applied  to  the  supra- 
pubic region  should  be  tried  first  in  an  effort  to  secure  complete  evac- 
uation of  the  bladder.  If  pain  is  extremely  severe,  tincture  of  hyos- 
cyamus  may  be  given  in  doses  of  one  to  three  minims,  three  times  a 
day;  or  a  suppository  of  powdered  opium  and  extract  of  belladonna, 
each  grain  j,  may  be  cautiously  used  for  its  relief. 

The  child  should  be  encouraged  to  drink  plenty  of  water,  and  by 
careful  regulation  of  the  diet  an  effort  should  be  made  to  prevent  hyper- 
acidity or  hyperalkalinity  of  the  urine  in  the  future.  Potassium  citrate 
is,  perhaps,  the  best  diuretic  in  this  affection,  and  may  be  given  to 
advantage  through  the  attack. 

VESICAL  CALCULI  (URETHRAL  CALCULI). 

Calculi  in  the  bladder  or  urethra  of  children  are  only  occasionally 
met  with.  Although,  during  infancy,  the  passage  of  renal  sand  or 
gravel  is  quite  common,  a  concretion  is  rarely  of  sufficient  size  to  be 
retained  within  the  bladder.  The  majority  of  calculi  contain  uric 
acid  and  urates,  the  remainder  being  mainly  oxalates  and  phosphates. 
The  tendency  to  formation  of  concretions  is  greatly  increased  by  any 
inflammatory  process  along  the  urinary  tract.  It  has  been  estimated 
that  vesical  calculi  are  twenty  times  as  common  in  boys  as  in  girls, 
a  fact  readily  explained  by  the  ease  with  w^hich  a  stone  may  escape 
from  the  bladder  through  the  short  and  distensible  female  urethra. 

Symptoms. — ^The  symptoms  of  vesical  calculus  are,  for  the  most 
part,  associated  with  the  act  of  micturition.  There  is  great  frequency 
of  urination,  accompanied  by  pain  more  or  less  intense,  and  referred 
to  the  end  of  the  penis,  to  the  perineum,  or  in  some  cases  to  the  rectum. 
The  stream  is  variable  and  uncertain,  and  may  be  interrupted  only 
to  be  resumed  after  a  change  in  posture.  In  some  cases  there  is  incon- 
tinence during  the  day,  but  rarely  during  sleep. 

If  the  calculus  be  impacted  in  the  urethra  there  may  be  a  constant 
dribbling  of  bloody  urine  and  efforts  to  dislodge  it.  Straining  during 
the  act  of  urination  often  causes  a  prolapse  of  the  rectum.  When 
violent  exercise  is  taken,  pain  is  usually  felt  in  the  bladder  region, 
but  this  quickly  subsides  upon  lying  down.  If  allowed  to  remain  in 
the  bladder  a  stone  quickly  causes  cystitis  with  characteristic  changes 
in  the  urine;  but,  in  the  absence  of  this  condition,  the  urine  usually 
shows  an  excess  of  crystals,  mucus,  a  little  pus,  and,  occasionall}',  blood. 

Diagnosis. — All  other  causes  of  vesical  irritation  must  be  excluded 
before  one  is  justified  in  considering  it  due  to  a  stone  in  the  bladder. 
Once  this  has  been  done,  the  diagnosis  may  usually  be  readily  con- 
firmed by  the  .r-ray,  the  use  of  the  sound,  and  bimanual  examination 
through  the  rectum. 

Treatment. — Surgical  remo\al  of  the  stone  is  practically  always  neces- 
sary; in  my  opinion,  suprapubic  lithotomy  is  preferable  to  lithoplaxy. 


570  DISEASES  OF   THE  GENITO-URINARY  SYSTEM 

If  the  stone  is  removed  before  complications  have  arisen,  recovery 
may  be  expected;  but,  as  a  rule,  these  children  are  very  weak  and 
anemic,  and  should  have  all  the  benefits  of  a  carefully  regulated, 
nourishing  diet,  and  change  of  location  to  seashore  or  country. 

URETHRITIS. 

Urethritis  occurs  in  both  sexes  during  childhood;  but,  owing  to 
the  prevalence  of  vulvovaginitis  with  which  it  is  usually  associated 
in  females,  it  is  far  more  common  in  girls  than  in  boys.  It  may  be 
either  simple  or  specific,  the  simple  form  being  but  a  slight  inflam- 
mation of  the  anterior  portion  of  the  penile  urethra  caused,  generally, 
by  lack  of  cleanliness  of  the  genitalia,  and  occasionally  by  injury  or 
the  passage  of  uric  acid  crystals. 

The  symptoms  are  very  mild,  and  consist  of  a  little  pain  on  urination, 
frequent  micturition,  and  a  slight  discharge  of  pus  which  contains 
leukocytes,  various  microorganisms,  and  a  few  epithelial  cells.  There 
is  usually  a  prompt  disappearance  of  symptoms  if  the  parts  are  simply 
kept  clean.  Irrigation  is  rarely  necessary  unless  the  discharge  per- 
sists, when  the  anterior  urethra  should  be  gently  syringed  out  daily, 
using  a  1  to  2000  potassium  permanganate  solution,  or  a  5  per  cent, 
solution  of  argyrol. 

Specific  Urethritis. — Gonorrheal  infection  of  the  urethra  in  children 
is  much  more  frequently  seen  than  the  simple  form,  but  rarely  occurs 
before  the  sixth  year  as  it  is  usually  contracted  through  direct  con- 
tagion. While  not  as  serious  a  disease  as  in  adults,  gonorrheal  urethri- 
tis, in  comparison  to  the  simple  or  non-specific  form,  is  a  very  severe 
infection,  and  is. not  confined  to  the  anterior  urethra,  but  may  involve 
the  posterior  urethra  as  well,  and  is  not  infrequently  complicated  by 
balanitis,  stricture,  epididymitis,  and  inguinal  adenitis. 

Orchitis  is  a  rare  complication,  but  though  there  are  few  constitu- 
tional symptoms  of  gonorrhea  in  the  child,  arthritis  and  conjuncti- 
vitis occur  not  infrequently  as  complications.  The  symptoms  are 
frequent  micturition,  accompanied  by  severe  burning  pain  on  urination 
and  a  profuse,  thick,  creamy  discharge  of  pus.  It  is  upon  the  micro- 
scopic examination  of  this  discharge  that  the  diagnosis  of  specific 
urethritis  is  based,  and  there  is  usually  very  little  difficulty  in  making 
the  diagnosis,  for  gonococci  are,  as  a  rule,  present  in  great  numbers. 

Treatment. — Much  attention  should  be  paid  to  prophylactic  measures, 
in  order  that  the  child's  brothers,  sisters,  and  playmates  may  not  be 
contaminated,  and  also  that  the  child  may  not  infect  other  parts  of 
its  own  body.  The  genitalia  should  be  kept  securely  covered  so  that 
the  child  cannot  touch  the  parts,  for  if  the  hands  become  contaminated 
the  infection  is  easily  spread. 

The  child  should  be  allowed  to  drink  plenty  of  water,  and  free 
diuresis  should  also  be  promoted  by  an  alkaline  diuretic,  such  as 
hexamethylenamin,  which  may  be  given  in  from  2-  to  5-grain 
doses,  three  times  a-  day,  according  to  the  age  of  the  patient.    If  the 


PHIMOSIS  571 

discharge  is  pro  use,  and  tends  to  persist,  it  is  best  to  irrigate  the 
anterior  urethra  with  a  1  to  500  bichloride  sohition,  or  a  5  per  cent, 
solution  of  argyrol. 

The  diet  should  be  bland  and  non-irritating,  and  all  spices,  seasoned 
foods,  beverages,  aside  from  milk  and  water,  should  be  prohibited. 
The  child  should  eat  sparingly  and  confine  the  diet  to  cereals,  bread, 
butter,  milk,  and  puddings,  with  a  few  vegetables,  and  little  meat. 

Physical  exertion,  if  carried  to  excess,  is  extremely  harmful,  but 
rest  in  bed  is  not  necessary.  Of  great  importance  is  the  condition 
of  the  bowels,  and  special  emphasis  should  be  placed  on  the  fact  that 
the  patient  must  have  one  or  two  soft  stools  daily.  A  properly  fitting 
suspensory  is  often  a  source  of  great  comfort  and  a  help  in  retaining 
the  dressing  while  the  discharge  persists. 


DISEASES  OF  THE  REPRODUCTIVE  ORGANS. 

PHIMOSIS. 

Phimosis  is  a  narrowing  of  the  orifice  of  the  prepuce  which  prevents 
the  withdrawal  of  the  foreskin  over  the  glans  penis,  and  frequently 
results  in  adhesions  between  the  inner  surface  of  the  prepuce  and  the 
mucous  membrane  of  the  glans.  Narrowing  of  the  orifice  of  the  pre- 
puce is  normal  in  very  young  infants,  and  should  be  corrected  early 
by  the  mother  or  nurse,  as  a  tight  foreskin  retains  the  smegma,  and 
is  a  constant  source  of  irritation.  In  time  it  may  interfere  with  the 
flow  of  urine,  and  cause  retention,  or  permit  the  passage  of  only  a  few 
drops  at  a  time,  which  frequently  gives  rise  to  stubborn  eczema  of 
the  genitalia. 

Nocturnal  incontinence  is  often  a  direct  result  of  phimosis,  and  in 
rare  cases,  also  of  hydronephrosis.  The  nervous  equilibrium  of  the 
child,  as  yet  undeveloped,  is  severely  deranged  by  the  constant  itching 
and  irritation.  As  a  result,  there  is  restlessness  and  peevishness 
during  the  day,  with  night  terrors  and  insomnia.  In  some  instances 
it  leads  to  the  habit  of  masturbation,  or  an  attack  of  hysteria  or 
chorea  comes  on.  Adherent  prepuce  in  little  girls  is  not  fraught  with 
as  much  danger  as  the  same  condition  in  boys;  but  it  has  been  claimed 
that,  if  allowed  to  persist,  the  result  will  be  hypererethism  or  sexual 
apathy  in  later  life. 

Treatment. — In  many  cases  of  phimosis,'  mere  stretching  of  the  fore- 
skin and  separation-  of  the  adhesions  will  relieve  the  condition,  after 
which  the  prepuce  should  be  drawn  back,  and  the  glans  cleansed 
thoroughly  every  day.  Circumcision,  while  more  radical,  is,  perhaps, 
the  best  and  safest  measure  with  which  to  secure  permanent  results. 


572  DISEASES  OF   THE  GEN  I TO-V  BINARY  SYSTEM 

PARAPHIMOSIS. 

Paraphimosis  is  a  condition  just  the  opposite  to  phimosis,  although 
due  to  the  same  cause.  The  narrow  foreskin  is  drawn  over  the  glans 
penis,  and  forms  a  tight  constricting  band  behind  the  corona.  The 
glans  soon  swells,  making  it  impossible  to  slip  the  foreskin  back  again 
o^'er  the  head  of  the  penis,  and  if  the  constriction  is  not  relieved  the 
intense  edema  and  failure  in  circulation  will  result  in  gangrene. 

Treatment. — The  penis  should  be  bathed  in  hot  or  cold  water,  and 
an  attempt  then  made  to  relieve  the  constriction  by  holding  the  fore- 
skin between  the  first  two  fingers  of  each  hand  and  exerting  pressure 
on  the  glans  with  the  thumbs  while  gentle  traction  is  being  made  on 
the  foreskin  with  the  fingers.  When  the  edema  is  marked,  multiple 
punctures  of  the  glans  are  sometimes  necessary  to  reduce  its  size. 
If  these  measures  fail,  and  the  circulation  is  not  established,  the  con- 
stricting band  must  be  promptly  incised  to  prevent  permanent  injury 
to  the  glans. 

BALANITIS. 

Balanitis  is  an  acute  inflammation  of  the  mucous  membrane  of  the 
glans  penis,  and  is  frequently  observed  in  children,  its  most  common 
cause  being  phimosis.  Lack  of  cleanliness  results  in  the  retention 
of  smegma  and  urine  between  the  glans  and  the  prepuce,  in  conse- 
quence of  which  the  mucous  membrane  of  the  glans  becomes  tender, 
swollen,  and  covered  with  pus,  and  the  foreskin  edematous  and  swollen. 
The  discharge  of  pus  may  be  so  free  as  to  suggest  urethritis. 

Treatment. — Daily  cleansing  of  the  parts,  followed  by  an  anti- 
septic wash  with  a  saturated  solution  of  boric  acid,  will  usually  effect 
a  cure  within  a  few  days.  Circumcision  is  indicated  if  the  prepuce 
be  tight  or  elongated,  but  should  not  be  performed  until  all  inflam- 
mation has  subsided. 

TORSION    OF    THE    SPERMATIC   CORD. 

Torsion  of  the  spermatic  cord  is  a  very  rare  occurrence,  and  prac- 
tically never  happens  except  in  those  children  where  the  testicle 
fails  to  descend  or  only  descends  partly.  When  the  testicle  becomes 
twisted  upon  the  cord,  circulation  is  cut  off  because  of  its  constricted 
condition,  and  gangrene  may  result  if  the  blood  supply  is  not  resumed 
quickly.  The  symptoms  resemble  closely  those  of  strangulated  hernia, 
and  it  is  also  difficult  to  differentiate  this  condition  from  acute  orchitis. 

Treatment. — The  treatment  is  surgical  and  depends  upon  the  length 
of  time  the  circulation  has  been  shut  oft'  and  the  resultant  condition 
of  the  tissues.  The  cord  should  be  untwisted  if  possible,  and  the 
testicle  slipped  back  into  place,  but  if  gangrene  is  present,  cord  and 
testicle  must  be  excised. 


•       TUBERCULOUS  ORCHITIS  573 

ACUTE    ORCHITIS. 

Acute  or  simple  orchitis  is  rare  during  childhood,  and  is  usually 
secondary  to  some  systemic  infection.  The  inflammation  begins 
in  the  epididymis.  Hydrocele  very  frequently  accompanies  acute 
inflammation  of  the  testicles,  but  has  no  bearing  on  the  severity  of 
the  process. 

Etiology. — In  children,  acute  orchitis  is  seen  occasionally  following 
urethritis,  but  a  fair  proportion  of  cases  occur  during  the  acute  infec- 
tions, especially  mumps,  typhoid  fever,  and  variola.  Authorities 
differ  as  to  the  prevalence  of  syphilitic  orchitis  in  infancy  and  early 
childhood,  but  from  my  own  observations  I  should  judge  it  to  be  rela- 
tively frequent.  Injury  to  the  testicles  is  often  followed  by  a  simple, 
mild  orchitis;  if  the  trauma  be  severe,  and  much  damage  has  been 
done  the  the  tissues,  gangrene  may  set  in. 

Symptoms  and  Pathology. — In  simple  orchitis  the  inflammation  in 
the  epididymis  is  essentially  catarrhal,  but  when  the  testicle  becomes 
involved  the  interstitial  tissue  is  invaded,  and  here  the  inflammation 
tends  to  become  almost  entirely  interstitial.  The  cardinal  symptoms 
are  pain  and  swelling,  and  the  size  of  the  scrotum  may  be  increased 
by  the  presence  of  a  hydrocele,  which  often  accompanies  acute  orchitis. 
The  pain  may  be  felt  in  the  loins,  but  is  most  severe  in  the  scrotum, 
which  may  also  be  red  and  edematous.  In  most  instances,  in  addition 
to  the  local  symptoms,  there  are  systemic  symptoms,  such  as  fever, 
anorexia,  and  malaise. 

Treatment. — The  child  with  acute  orchitis  should  be  put  to  bed  and 
kept  there  until  recovery  ensues.  The  testicles  must  be  supported 
by  stretching  a  wide  strip  of  adhesive  plaster  from  the  anterior  por- 
tion of  one  thigh  to  the  other,  and  allowing  the  scrotum  to  rest  upon 
it.  Ice-bags  are  useful  if  applied  to  the  scrotum  in  the  very  early 
stages  of  the  inflammation;  but,  after  this  time,  heat  is  more  service- 
able, and  should  be  applied  by  means  of  hot  compresses  renewed 
frequently. 

A  saline  laxative  preceded  by  a  course  of  calomel,  is  of  great  bene- 
fit, and  is  practically  the  only  internal  medication  that  is  of  any  value. 
The  course  of  the  inflammatory  process  should  be  watched  closely, 
and  if  suppuration  sets  in  the  testicle  should  be  freely  mcised  and 
the  pus  allowed  to  escape.  The  child  must  wear  a  suspensory  ban- 
dage for  several  weeks  after  the  attack,  for  in  some  instances  atrophy 
of  the  testicle  follows  acute  orchitis.  Free  circulation  of  the  blood 
should  be  encouraged  in  every  way  possible. 

TUBERCULOUS    ORCHITIS. 

There  are  two  forms  of  tuberculous  orchitis  occurring  in  children, 
and  it  is  important  that  each  form  should  be  recognized  as  such. 
Involvement  of  the  testicles  in  children  with  general  tuberculosis 
is  the  most  common  type,  and  more  rarely  is  it  seen  as  a  part  of  a 


574  DISEASES  OF   THE  GEXITO-URIXARY  SYSTEM 

generalized  tuberculosis  of  the  genito-urinary  tract  alone.  Both 
testicles  are  in^■oh'ed,  as  a  rule,  the  tuberculous  process  beginning  in 
the  epididymis. 

Etiology. — Tuberculous  orchitis  is  a  secondary  process  in  almost 
every  instance,  the  infection  having  been  carried  to  the  epididymis 
through  the  lymphatics,  blood  stream,  or  vas  deferens.  Occasionally 
one  may  obtain  a  distinct  history  of  trauma,  which  has  probably 
been  an  important  predisposing  factor  in  determining  the  testicles 
as  a  site  of  the  tuberculous  lesion. 

Symptoms  and  Pathology. — The  testicle  in  Avhich  a  tuberculous  pro- 
cess is  going  on  becomes  a  hard  indurated  mass  as  in  adults,  and  if 
the  child  resists  the  effects  of  the  s}'stemic  infection,  which  is  usually 
present,  this  mass  breaks  down,  suppuration  takes  place,  the  tunica 
vaginalis  is  inA'olved,  the  skin  ulcerates,  and  a  sinus  forms.  The  cord 
is  always  thickened.  The  local  symptoms  are  pain  and  swelling,  for 
in  children  tuberculous  orchitis  may  be  very  acute,  and  a  large  tumor 
form  in  a  very  short  period  of  time.  Other  sAHiptoms  of  tuberculosis 
are  usually  present  throughout  the  body  and  aid  in  the  diagnosis, 
but  even  without  these  additional  signs,  if  tubercle  bacilli  are  found 
in  the  discharge  from  the  sinus,  the  diagnosis  is  established  without 
doubt. 

Prognosis. — The  prognosis  of  tuberculous  orchitis  is  much  better 
in  children  than  in  adults,  as  the  tendency  for  the  process  to  spread 
and  involve  the  surrounding  tissues  is  much  less  marked  and  the 
infection  does  not  assume  as  serious  an  aspect. 

Treatment. — The  testicles  should  be  treated  locally,  palliative  meas- 
ures at  first,  such  as  pressure  and  the  application  of  iodide  of  lead 
ointment.  Castration  should  be  performed  early  where  the  danger 
of  general  infection  of  tuberculosis  is  to  be  feared,  but  should  not  be 
undertaken  until  the  diagnosis  is  definitely  established  and  suppuration 
is  taking  place.  In  every  case,  whether  other  lesions  of  tuberculosis 
are  found  elsewhere  in  the  body  or  not,  the  child  should  receive  the 
benefit  of  all  the  hygienic,  dietetic,  and  medicinal  measures  with  which 
tuberculous  children  are  treated.  Fresh  air  is  indispensable  both  night 
and  day,  the  food  should  be  highly  nutritious,  and  the  child  should 
obtain  the  proper  amount  of  exercise  and  rest  to  materially  build  up 
the  general  physical  condition. 

TUMORS    OF    THE    TESTICLE. 

Tumors  of  the  testicle  are  rarely  seen  during  childhood,  and,  in 
not  a  few  cases  where  the  existence  of  a  neoplasm  is  suspected,  care- 
ful study  and  investigation  will  prove  the  growth  to  be  a  tuberculous 
process  which  has  extended  from  the  epididATuis.  Congenital  growths 
are  usually  malignant,  and  either  carcinomatous  or  sarcomatous,  but 
occasionally  one  sees  a  benign  growth,  an  enchondroma  or  myoma. 
Acquired  growths  of  the  testicle  are,  as  a  rule,  extremely  malignant, 
the  round-cell  sarcoma  being  the  most  common.     Cystic  disease  of 


VULVOVAGINITIS  575 

the  testicle  occurs  with  relative  frequency  in  childhood,  and  is  always 
a  serious  problem,  since  it  is  impossible  to  differentiate  simple  cystic 
disease  from  sarcoma. 

Symptoms. — Tumors  of  the  testicle  are  most  common  from  the 
first  to  the  tenth  year  of  life.  There  are  very  few  symptoms  of  malig- 
nancy at  the  onset  of  the  disease,  but  the  tumor  grows  very  rapidly 
in  size,  and  with  this  increased  growth  there  is  a  progressive  feeling 
of  discomfort  and  weight.  The  tumor  sometimes  becomes  quite 
large  before  constitutional  symptoms  of  malignancy  and  cachexia  are 
apparent. 

Treatment. — In  view  of  the  fact  that  most  tumors  of  the  testicle 
are  malignant,  and  in  those  which  are  not  so  at  the  onset  there  is  an 
ever-present  possibility  of  malignancy,  a  surgical  operation  for  the 
removal  of  the  testicle  should  always  be  advised  when  it  is  the  site 
of  a  new  growth. 

VULVOVAGINITIS. 

Vulvovaginitis  is  not  an  uncommon  condition  in  little  girls  between 
the  ages  of  two  and  eight  years,  but  rarely  occurs  in  infancy.  The 
mucous  membrane  of  the  vulva  is  inflamed  and  swollen,  and  the  pro- 
cess may  extend  into  the  vagina,  and,  in  rare  instances,  involve  the 
urethra  and  cervix  uteri.  The  majority  of  cases  are  not  specific,  but 
in  the  poorer  classes,  especially,  gonorrheal  vulvovaginitis  occurs  quite 
frequently.  Diphtheritic  and  aphthous  vulvovaginitis  are  extremely 
rare  forms  sometimes  seen  in  large, institutions. 

Simple  Vulvovaginitis. — Simple  vulvovaginitis  is  usually  a  mild 
catarrhal  inflammation,  confined  for  the  most  part  to  the  vulva,  and 
accompanied  by  a  serous  discharge;  but  not  infrequently  one  encounters 
a  severe  case  with  intense  inflammation  of  the  \iilva  and  vagina,  and 
a  profuse  purulent  discharge.  The  urethral  orifice  and  cervix  uteri 
may  be  involved,  and  the  whole  aspect  of  the  case  resemble  a  specific 
infection.  Microscopically,  the  discharge  is  found  to  contain  numer- 
ous bacilli  and  cocci,  but,  while  the  cocci  resemble  gonococci  in  some 
respects,  they  do  not  exhibit  all  the  characteristics  of  this  organism. 

Etiology. — Simple  vulvovaginitis  is  caused  by  uncleanliness  in  the 
majority  of  cases,  the  mucous  membrane  of  the  genitalia  becoming 
contaminated  from  collections  of  smegma,  the  irritation  of  decompos- 
ing secretions  which  have  accumulated,  or  from  eczema  of  the  adjacent 
skin  surfaces.  Occasionally  the  inflammation  is  due  to  the  habit  of 
masturbation,  local  injury  to  the  parts  (attempted  rape,  etc.)  or  to 
scratching  in  the  case  of  scabies,  eczema,  or  threadworms. 

Delicate  and  anemic  children  whose  constitutions  have  been  under- 
mined by  tuberculosis,  malnutrition,  poor  hygienic  surroundings,  or 
a  recent  acute  contagious  disease,  are  especially  liable  to  vulvovagin- 
itis, and  here  we  have  the  probable  explanation  of  the  rapidity  with 
which  an  epidemic  spreads  through  the  wards  of  an  institution  when 
a  child  with  vulvovaginitis  is  admitted.  The  exact  means  of  trans- 
mission from  one  child  to  another  has  not  been  satisfactorilv  deter- 


576  DISEASES  OF   THE  GEN ITO-URI NARY  SYSTEM 

mined,  but  there  is  no  doubt  as  to  the  highly  contagious  nature  of 
the  discharge. 

Sym.ptoins. — In  mild  cases,  local  symptoms  of  inflammation  are 
so  slight  that  the  existence  of  the  disease  is  first  brought  to  notice  by 
the  appearance  of  the  discharge,  which  is  usually  serous  and  scanty, 
and  close  inspection  of  the  parts  reveals  a  little  redness  and  swelling 
which,  however,  are  limited  to  the  external  genitalia.  There  may  be 
a  little  local  tenderness  and  a  slight  itching,  intensified  on  urination. 

Simple  vulvovaginitis  may  be  of  such  a  severe  type  as  to  present 
all  the  characteristics  of  a  gonorrheal  infection,  and  in  these  cases 
it  can  only  be  difterentiated  by  careful  and  thorough  microscopic 
study  of  the  discharge.  The  labia  are  red,  swollen,  and  may  be  ulcer- 
ated; the  vagina  is  inflamed,  and  the  urethral  orifice  and  hymen  are 
also  involved.  The  parts  are  bathed  in  a  profuse,  thin,  greenish- 
yellow  discharge,  and  m-ination  is  attended  by  much  pam. 

If  the  adjacent  skin  becomes  excoriated  walking  is  painful,  and  the 
child  assumes  a  straddling  gait  to  prevent  friction  of  the  parts.  In 
some  instances  there  is  a  moderate  elevation  of  temperature  at  the 
onset,  but  this  falls  to  normal  after  the  acute  symptoms  have  subsided. 

Prognosis. — A  mild  vulvovaginitis  may  last  two  or  three  weeks, 
but  the  severe  type  usually  continues  for  one  or  two  months.  Com- 
plications, such  as  cystitis  and  urethritis,  are  rare,  and  a  complete  and 
uneventful  recovery  will  follow  the  institution  of  proper  treatment. 

Treatment. — Vulvovaginitis  responds  readily  to  gentle  irrigation 
with  either  saturated  boric  acid  solution,  sulphocarbolate  of  zinc 
solution,  or  a  weak  solution  of  potassium  permanganate.  The  solu- 
tion should  be  fairly  hot  (108°  F.)  and  its  use  should  be  preceded 
by  thorough  cleansing  of  the  genitalia  and  adjacent  skin  surface  with 
soap  and  water. 

If  the  labia  be  excoriated,  a  soothing  antiseptic  ointment,  contain- 
ing 1  per  cent,  phenol  and  1  per  cent,  hydrargyri  ammoniata,  will 
allay  the  burning  sensation  and  protect  the  parts  from  the  discharges, 
and  a  pledget  of  cotton  interposed  between  the  labia  will,  by  keeping 
them  separated,  prevent  friction.  In  my  experience,  I  have  found  the 
use  of  an  ointment  preferable  to  dusting  powders,  which  are  apt  to 
cake  when  they  become  moist,  and  thus  cause  additional  irritation. 

The  general  health  of  the  majority  of  these  children  is  poor,  and 
improvement  in  the  living  conditions,  together  with  the  administra- 
tion of  a  tonic,  such  as  cod-liver  oil  or  the  syrup  of  the  iodide  of  iron, 
will  materially  hasten  recovery.  In  every  case  the  etiological  factor 
should  be  ascertained  and  removed,  and  prophylactic  measures 
instituted  to  prevent  the  spread  of  the  infection  to  other  children. 

Gonorrheal  Vulvovaginitis. — Gonorrheal,  or  true,  vulvovaginitis  is 
by  no  means  an  uncommon  affection  in  little  girls  of  the  poorer  classes 
between  the  ages  of 'two  and  eight  years,  since  at  this  age  it  is  not  a 
venereal  disease,  but  is  contracted  accidentally  because  of  close  seg- 
gregation.  It  is  one  of  the  most  highly  contagious  diseases  met  with 
in  institutions,  and  epidemics,  once  begun,  are  rarely  checked  until  the 


VULVOVAGINITIS  577 

majority  of  the  female  children,  if  not  all  of  the  inmates,  are  attacked. 
The  infection  is  far  more  virulent  and  serious  than  simple  vulvovagin- 
itis, is  very  resistant  to  treatment,  and,  as  a  rule,  runs  a  protracted  course. 

Etiology. — In  the  majority  of  cases  of  vulvovaginitis  seen  in  pri- 
vate practice,  it  has  been  contracted  accidentally  by  children  sleeping 
with  adults,  using  their  towels  and  toilets,  or  bathing  in  the  same  tub. 
Older  children  may  be  contaminated  by  their  playmates  manipulating 
the  sexual  organs,  and  contamination  of  the  vagina  is  frequently 
traced  to  nurse  girls,  but  rarely  is  vulvovaginitis  the  result  of  a 
criminal  assault. 

Infants  have  been  known  to  become  infected  in  their  passage  through 
the  birth  canal,  but  during  infancy  this  disease  is  usually  transmitted 
through  the  medium  of  the  napkins. 

The  exact  way  in  which  the  contagion  spreads  in  institutions,  despite 
strictest  prophylaxis  and  antisepsis,  is  so  obscure  that  the  theory  of 
atmospheric  infection  has  been  advanced,  and  although  one  hesitates 
to  accept  this,  in  view  of  the  fact  that  nurses  in  charge  do  not  become 
infected,  it  is  only  by  isolation  that  the  disease  is  finally  eradicated. 
There  can  be  no  doubt  that  the  prevalence  of  the  disease  is  very  much 
increased  by  the  poor  general  condition  of  health  so  common  in  children 
of  institutions  and  the  slums. 

Symptoms. — The  severity  of  an  attack  of  vulvovaginitis  is  extremely 
variable,  and  while  the  extent  of  the  inflammation  is  modified  by  the 
virulence  of  the  infecting  organism  and  the  constitutional  condition  of 
the  patient,  records  of  a  large  number  of  cases  show  that,  as  a  general 
rule,  the  younger  the  child,  the  milder  the  attack.  The  inflammation  is 
at  first  severe  and  the  discharge  profuse,  but  in  many  cases  the  disease 
is  either  discovered  accidentally  during  routine  examination  of  chil- 
dren, or  the  physician  is  consulted  because  of  the  discharge  alone, 
other  symptoms  being  so  mild  as  to  escape  observation. 

The  discharge  varies  greatly  and  may  be  largely  mucus,  muco- 
pus,  or  a  thin,  serous,  greenish-yellow  fluid,  but  the  characteristic 
discharge  in  gonorrheal  vulvovaginitis  is  a  thick,  creamy,  yellow  pus, 
which,  when  examined  under  the  microscope,  is  found  to  contain  the 
gonococcus  in  practically  every  case  and  but  few  other  organisms. 
Infants  and  young  children  may  show  no  other  local  sign  of  inflam- 
mation than  a  slight  hyperemia  of  the  mucous  membrane  of  the  vulva 
and  orifice  of  the  vagina,  with  a  few  crusts  on  the  labia;  but  in  older 
children  there  is  usually  redness  and  swelling  of  the  vulva  and  A'agina, 
and  in  some  instances  the  skin  and  mucous  membrane  become  excor- 
iated and  even  ulcerated. 

The  urethra  rarely  escapes,  although  the  bladder  is  not  frequently 
involved.  The  cervix  uteri  becomes  inflamed  and  an  endocervicitis 
results,  but  extension  of  the  process  into  the  internal  pelvic  organs 
is  extremely  rare.  The  inguinal  glands  are  found  to  be  enlarged  in 
some  cases,  and  accompanying  this  there  may  be  a  slight  elevation 
of  temperature  which,  however,  subsides  after  the  acute  symptoms 
have  passed. 
37 


578  DISEASES  OF   THE  GENITO-URINARY  SYSTEM 

Irritation  of  the  parts  produced  by  walking  causes  the  child  to 
assume  a  straddling  gait  which  is  very  much  exaggerated  if  there 
are  excoriations  of  the  thighs  and  labia.  Uretliral  involvement  very 
often  gives  rise  to  painful  micturition,  and  in  every  case  there  is 
increased  frequency  of  urination,  which  causes  nocturnal  and  diurnal 
enuresis. 

Diagnosis. — A  positive  diagnosis  of  gonorrheal  vulvovaginitis  can 
only  be  made  when  gonococci  are  found  in  the  vaginal  smears;  and, 
therefore,  it  is  important  to  obtain  a  smear  in  every  case  of  vulvovagin- 
itis, even  though  the  discharge  be  very  scant.  In  some  instances  one 
may  only  be  able  to  state  that  the  cocci  present  the  characteristics 
of  the  gonococci,  and  at  times  cultures  must  be  made  before  it  can 
be  positively  determined  that  the  organism  is  the  gonococcus;  but 
the  finding  of  gram  negative  intracellular  diplococci  is  accepted  as 
conclusive  evidence  of  Nisserian  infection. 

Those  smears  in  which  we  find  the  gonococcus  usually  contain  few 
other  organisms,  and  so  true  is  this  observation  that,  although  the 
gonococcus  may  not  be  demonstrated,  if  very  few  other  organisms 
are  found,  one  should  be  highly  suspicious  of  specific  infection.  In 
non-specific  or  catarrhal  vulvovaginitis  the  discharge  is  usually  com- 
posed of  an  abundance  of  several  varieties  of  cocci  and  bacilli.  If  the 
facilities  are  not  at  hand  thoroughly  to  examine  smears  and  make 
cultures,  any  case  of  vulvovaginitis  which  is  accompanied  by  a  profuse, 
purulent  discharge  should  be  considered  specific,  and  be  treated  as  such. 

Course  and  Complications. — Gonorrheal  vulvovaginitis  runs  an 
essentially  protracted  course;  from  six  to  eight  weeks  is  the  shortest 
period  in  which  recovery  ever  occurs,  and  in  most  cases  three  or  four 
months  or  longer  are  required  for  its  cure.  The  two  complications 
which  the  practitioner  must  be  warned  against  are  ophthalmia  and 
arthritis,  for  they  are  seen  occasionally  and  should  be  recognized  and 
treated  immediately.    Endocarditis,  septicemia,  and  pyemia  are  rare. 

Prognosis. — Despite  its  protracted  course  the  ultimate  outlook  of 
a  case  of  vulvovaginitis  in  the  absence  of  complications  is  good.  The 
fact  that  gonococci  may  remain  latent  in  the  genital  tract  for  an  almost 
indefinite  period  should  not  be  overlooked,  however,  as  this  is  no  doubt 
responsible  for  the  numerous  relapses  which  occur. 

Prophylaxis. — The  extremely  infectious  nature  of  gonorrheal  vulvo- 
vaginitis makes  the  consideration  of  prophylactic  measures  of  utmost 
importance.  In  the  home,  if  one  child  is  affected,  it  should  be  isolated 
from  the  others  in  so  far  as  this  is  possible,  and  at  least  all  relations 
or  associations  with  other  children  should  be  avoided.  This  refers 
particularly  to  the  child's  clothing,  bed  linen,  towels  and  table  silver, 
which  should  be  kept  apart  at  all  times  from  those  of  the  rest  of  the 
family. 

The  child  should  bathe  in  a  tub  which  no  one  else  is  allowed  to  use, 
should  use  a  separate  toilet,  and  should  wear  pads  which  are  changed 
frequently  and  the  soiled  ones  burned.  Too  much  attention  cannot 
be  directed  to  the  necessity  of  absolute  cleanliness,  and  this  is  espe- 


VULVOVAGINITIS  579 

cially  important  with  regard  to  the  hands,  which,  if  soiled,  may  easily 
be  the  means  of  conveying  the  disease  to  other  children. 

Prophylactic  measures  must  be  carried  out  to  even  a  greater  degree 
if  epidemics  are  to  be  avoided  in  institutions  where  children  are  con- 
gregated together.  Every  applicant  for  admission  should  be  thoroughly 
examined  for  vaginal  discharge,  and  even  if  the  microscopic  exam- 
ination of  a  discharge  be  negative,  the  patient  should  be  isolated  for 
at  least  two  weeks  and  repeated  examinations  made,  for  in  a  large 
number  of  cases  where  thorough  study  of  the  discharge  is  made  one 
is  able  eventually  to  demonstrate  the  gonococcus. 

The  routine  examination  of  all  children  in  institutions  twice  or 
three  times  a  week  is  recommended  as  the  only  means  to  eradicate 
the  disease.  Children  isolated  because  of  a  discharge  should  be  under 
the  care  of  special  nurses;  for  it  is  practically  impossible  for  a  nurse 
to  attend  a  child  with  vulvovaginitis  without  conveying  the  disease  to 
other  children.  Care  must  be  taken  to  disinfect  all  linen  and  clothing 
before  allowing  it  to  go  to  the  general  laundry,  and  all  pads  and 
dressings  should  be  burned. 

A  nurse  treating  more  than  one  case  of  vulvovaginitis  should  care- 
fully cleanse  and  disinfect  her  hands  after  attending  each  patient, 
and  should  see  that  the  toilets  and  tubs  are  disinfected  each  time  they 
are  used  in  order  to  prevent  reinfection  of  convalescent  patients. 
It  is  unwise  to  allow  any  patient  to  mingle  with  other  children  until 
there  is  absolutely  no  vaginal  discharge  remaining,  for  in  many 
instances  fresh  outbreaks  of  vulvovaginitis  have  followed  where 
children  have  been  taken  out  of  quarantine,  simply  because  there 
were  no  gonococci  demonstrable  in  the  vaginal  secretions. 

Treatment. — Cleanliness  of  the  parts  is  the  prime  essential  in  the 
successful  treatment  of  gonorrheal  vulvovaginitis,  and  this  is  mainly 
secured  by  means  of  douching  and  flushing  the  vagina.  In  the  initial 
stage,  when  the  inflammation  is  severe,  a  vaginal  douche  should  be 
given  three  or  four  times  daily,  using  at  least  two  c{uarts  of  either  a 
1  to  5000  potassium  permanganate,  or  1  to  5000  bichloride  solution, 
the  temperature  of  which  should  be  about  106°  to  108°  F. 

The  use  of  various  other  irrigating  fluids,  such  as  normal  saline, 
boric  acid,  and  silver  salts  solutions  will,  perhaps,  be  found  to  give 
equally  good  results,  since  the  real  benefit  of  the  douche  is  apparently 
due  to  its  cleansing  effect  more  than  to  anything  else.  The  female 
catheter  is  undoubtedly  the  best  irrigating  nozzle  for  this  purpose, 
but  care  should  be  taken  not  to  insert  it  too  far  or  injure  the  parts 
in  any  way,  or  force  the  solution  into  the  uterine  cavity  by  allowing 
the  stream  to  flow  too  swiftly. 

If  the  child  be  under  the  care  of  inexperienced  persons  it  is  some- 
times wiser  to  omit  douching,  and  simply  allow  the  child  to  sit  in 
a  large  basin  partly  filled  with  warm  boric  acid  or  saline  solution, 
several  times  a  day.  In  addition  to  this  the  vagina  may  be  packed 
with  cotton  saturated  with  weak  solutions  of  potassium  permanganate, 
bichloride,  or  one  of  the  various  silver  salts. 


580  DISEASES  OF   THE  GENITO-URINARY  SYSTEM 

Strong  applications,  such  as  2  to  5  per  cent,  silver  nitrate  or  pro- 
targol  solutions,  or  10  to  20  per  cent,  solutions  of  argjTol,  are  often 
used  advantageouly  after  irrigating,  and  may  be  either  daubed  on 
with  a  swab  or  instilled  in  small  quantities  into  the  vagina.  A  vulvar 
pad  should  be  worn  constantly,  and  changed  as  frequently  as  the 
amount  of  discharge  necessitates,  and  whenever  the  underclothing  is 
soiled,  fresh  linen  should  be  put  on  lest  the  child  be  reinfected  by  the 
soiled  garments. 

Care  should  be  taken  that  the  child's  hands  do  not  become  con- 
taminated, and  the  danger  of  infecting  the  eyes  should  be  explained 
to  the  nurses  and  attendants,  who  should  be  instructed  to  burn  all 
pads  and  dressings  and  disinfect  all  soiled  clothing  before  having  it 
laundered.  At  the  best,  recovery  is  a  slow  and  tedious  process,  and 
relapses  are  common;  and  if  a  case  is  unusually  protracted  vaccine 
treatment  is  sometimes  resorted  to  with  excellent  results. 

Stock  vaccines  are  quite  as  effective  as  autogenous,  and  the  dose 
should  be  gradually  increased  from  an  initial  injection  of  fifty  million 
up  to  one  or  two  hundred  million  within  a  week.  If  the  facilities  are 
at  hand  it  is  always  advisable  to  determine  the  opsonic  index  before 
and  after  a  dose  of  the  vaccine,  in  order  to  calculate  the  exact  effect 
of  the  treatment;  although  no  untoward  effects  have  ever  followed 
the  administration  of  these  vaccines  in  this  manner. 

Because  of  the  poor  general  health  of  these  children,  they  improve 
much  more  quickly  if,  in  addition  to  local  treatment,  they  are  removed 
to  the  seashore  or  country,  and  given  a  good  nutritious  diet.  The 
general  constitutional  condition  should  be  built  up  by  the  adminis- 
tration of  tonics  such  as  the  syrup  of  ferrous  iodide,  or  cod-liver  oil. 

GANGRENE    OF    THE   VULVA. 

Gangrene  of  the  \'uh'a,  or  noma  vulvae,  is  a  condition  analogous 
to  cancrum  oris,  and  differs  from  that  disease  only  as  to  the  site  of 
the  lesion.  It  usuall\^  occurs  in  greatly  debilitated  children,  following 
one  of  the  acute  infections,  commonly  measles  or  diphtheria,  or  may 
arise  during  the  course  of  enteric  fever  or  dysentery.  It  never  occurs 
primarily  except  where  great  injury  has  been  done  to  the  parts,  as 
in  severe  crushing  or  by  the  continued  application  of  strong  alkalies 
or  acids. 

A  swelling  of  one  of  the  labia  is  usually  the  first  symptom  of 
approaching  gangrene,  after  which  the  part  becomes  indm-ated  and 
finally  breaks  down,  forming  a  foul-smelling,  sloughing  ulcer,  which 
spreads  rapidly,  invading  the  surrounding  tissues.  The  prognosis 
is  nearly  always  hopeless,  because  of  the  already  weakened  condition 
of  the  patient,  and  the  rapidity  with  which  the  gangrene  spreads 
through  the  devitalized  tissues,  and  affects  the  whole  constitution 
by  the  absorption  of  toxins. 

Treatment. — Wide  excision  offers  the  best  chance  of  checking  the 
disease,  but  is  not  always  possible  because  of  the  close  proximity 


MENSTRUATION  PRECOX  581 

of  iinportunt  structures.  Cauterization  is  sometimes  followed  by 
tlimiiuition  in  the  severity  of  the  gangrenous  process,  and  may  enable 
the  physician  to  get  it  under  controL  The  parts  should  be  cleansed 
ever  so  often,  and  the  child's  strength  should  be  supported  by  an 
abundance  of  nourishing  food  and  stimulants  at  frequent  intervals. 

VICARIOUS   MENSTRUATION. 

Vicarious  menstruation  is  exceedingly  rare  in  children,  but  occurs 
with  sufficient  frequency  to  demand  recognition.  The  cause  is 
unknown.  In  many  instances  there  is  precocious  development  of 
the  genitalia  or  of  the  whole  body,  and,  although  vicarious  menstru- 
ation, in  itself,  is  not  particularly  harmful  unless  the  hemorrhage  is 
severe,  the  resultant  anemia  from,  for  example,  a  periodical  epistaxis 
every  three  or  four  weeks,  lasting  for  from  two  to  five  days,  would  be 
quite  serious  in  delicate,  tubercular,  or  syphilitic  children. 

Treatment. — There  is  no  know^n  treatment  which  has  any  influence 
on  the  occurrence  of  the  hemorrhages  of  vicarious  menstruation,  there- 
fore attention  should  be  directed  to  keeping  up  the  child's  nutrition 
and  combating  the  anemia.  The  diet  should  be  carefully  regulated, 
so  that  the  amount  of  nutrition  received  is  the  maximum,  with  a 
minimum  effect  on  the  gastro-intestinal  tract. 

Iron  is,  perhaps,  the  one  best  drug  for  these  children,  and  may  be 
given  as  the  syrup  of  ferrous  iodide  in  10-drop  doses,  three  times  a 
day,  to  a  child  of  five  years,  or  one  of  the  various  easily  assimilable 
preparations  of  iron  may  be  included  in  a  tonic  mixture.  Where 
the  opportunity  presents  itself,  these  children  should  spend  a  few 
months  each  year  at  the  seashore  or  in  the  mountains. 

MENSTRUATION   PRECOX. 

Menstruation  precox  is  very  rare  in  early  childhood,  but  it  is 
not  an  uncommon  occurrence  in  the  United  States  for  girls  of  eight 
and  ten  years  to  menstruate  regularly.  In  these  latter  instances, 
the  subjects  are  either  very  strong  and  healthy  or  very  delicate, 
but  very  young  children  who  menstruate  are  usually  overdeveloped, 
mentally  and  bodily. 

Many  of  the  delicate  children  who  menstruate  too  early  have 
syphilis  or  tuberculosis,  which  may  be  responsible  indirectly  for  the 
condition,  because  of  its  effect  on  the  constitution. 

Symptoms. — As  in  adults,  the  periods  may  last  from  one  to  five  days, 
but  they  are  much  more  irregular  as  to  the  time  of  their  occurrence, 
and  in  some  instances,  after  one  or  two  periods,  menstruation  will 
cease  till  puberty.  During  the  periods  the  symptoms  resemble  those 
in  adult  life,  and  the  child  is  restless,  nervous,  and  has  colicky  pains 
in  the  abdomen,  slight  fever,  swelling  of  the  mammae,  shows  a  change 
of  disposition,  and  even  a  certain  amount  of  sexual  excitement. 

When  the  period  is  missed  there  are  also  sensations  of  discomfort 


582  DISEASES  OF   THE  GEN  I  TO-URINARY  SYSTEM 

and  other  signs  like  those  in  the  aduh.  Before  one  may  definitely 
state  that  a  given  case  is  one  of  menstruation  precox,  bleeding  from 
the  genitalia  from  other  causes,  such  as  masturbation  and  severe 
vaginitis,  must  be  excluded,  and  the  periodicity  of  the  vaginal  discharge 
of  blood  must  be  definitely  established. 

Treatment. — A  child  who  menstruates  several  years  before  it  should 
normally  had  better  be  kept  in  bed  during  each  period.  An  ice- 
bag  sometimes  gives  relief  to  pain  if  placed  over  the  uterus,  but  cool- 
ing drinks  are  apt  to  cause  pain,  while  warm  liquids  are  often  very 
soothing. 

If  bleeding  be  profuse,  the  fluidextract  of  ergot  may  be  given 
in  10-drop  doses  three  times  a  da}'  to  a  child  of  five  years;  stypticm, 
grain  ^  to  |  three  times  a  day,  may  be  used,  the  dose  of  this  drug 
varying  according  to  the  age  of  the  child  and  degree  of  hemorrhage; 
hydrastin  may  be  given  in  the  form  of  hydrastin  hydrochlorate,  in 
doses  of  from  2V  to  yV  of  a  grain. 

MASTURBATION. 

Mastm'bation  is  not  an  uncommon  practice  during  childhood  and 
is  also  seen  quite  frequently  diuing  infancy,  although  rarely  before 
the  first  year.  In  older  children  this  practice  is  much  more  common 
in  boys,  but  from  my  observations  of  this  condition  in  infancy  I 
believe  that  it  occm's  in  female  infants  much  more  frequently  than  in 
males.  Thigh  rubbing,  and  not  manual  manipulation  of  the  genitalia, 
is  invariably  the  method  of  exciting  the  orgasm  in  infantile  mastur- 
bation, and  for  this  reason  it  has  been  regarded  as  pseudomasturbation 
by  some  authors. 

Etiology. — Thigh  friction  dm-mg  infancy  is  usually  begun  because 
of  some  irritation  of  the  genitalia  or  buttocks,  w^hich  has  induced 
rubbing  of  the  parts  to  allay  the  itching.  Lack  of  cleanliness  of  the 
thighs,  buttocks,  and  genitalia  is,  perhaps,  the  most  important  factor 
which  incites  the  habit  of  mastm^bation,  for,  as  a  result  of  accumu- 
lations of  secretions  and  excretions,  a  balanitis  or  vulvitis  of  a  mild 
degree  exists,  which  is  often  the  excitmg  cause.  Seatworms,  highly 
acid  urine,  eczema  of  the  adjacent  skin,  and  even  too  tight  clothing 
are  many  times  responsible  for  the  habit. 

There  can  be  no  doubt  that  the  general  physical  condition  of  these 
children  plays  an  important  part  in  determmmg  the  establishment 
of  the  act  of  masturbation,  and  in  many  cases  one  may  obtain  a 
definite  history  of  inherited  neurotic  tendencies,  which  have  been 
fostered  and  aggravated  by  the  child's  environment  and  lack  of  care. 

In  rare  instances  it  occurs  in  children  where  no  local  or  general 
cause  can  be  found,  and  under  these  chcumstances  one  should  always 
suspect  and  look  for  other  signs  of  mental  deficiency.  In  children 
of  seven  years  and  over  who  masturbate  we  must  consider  other 
factors  which  are  in  no  way  related  to  this  habit  during  infancy,  for 
at  this  age  not  micommonly  true  sexual  feelmg  is  incorporated  in 


MASTURBATION  583 

the  act,  especially  when  it  has  developed  because  of  surroundings  of 
immorality. 

I  am  convinced  that  in  but  few  cases  of  masturbation  in  older 
children  has  the  habit  been  contracted  accidentally,  as  in  washing 
the  genitalia,  scratching  to  allay  irritation,  or  in  climbing;  and  that 
imitation  of  the  act  by  younger  children  who  see  their  more  mature 
playmates  perform  it,  and  initiation  of  children  to  this  habit  by 
nurse  girls  and  attendants,  are  its  two  most  frequent  causes  at  this  age. 

Symptoms. — Infants  usually  masturbate  by  holding  the  thighs 
close  together  and  moving  the  whole  body  so  as  to  produce  friction; 
sometimes  an  infant  will  be  seen  to  perform  a  series  of  backward 
and  forward  and  side-to-side  movements  while  lying  on  the  back,  and 
still  others  lie  on  the  abdomen  and  rub  the  genitalia  on  a  pillow  or 
the  bed. 

The  variety  of  methods  adopted  is  endless,  but  in  each  case  the  effect 
produced  is  the  same;  the  child's  exertions  become  more  marked  with 
each  movement  and  nervous  excitation  increases,  the  face  becomes 
flushed  and  covered  with  perspiration;  at  the  height  of  the  act  a  few 
grunts  may  be  emitted,  after  wdiich  the  movements  cease  and  the 
child  falls  back  exhausted  and  pallid. 

Rarely  are  any  ill-effects  noticeable  in  infants  addicted  to  masturba- 
tion, although  the  already  unstable  condition  of  the  nervous  system 
is  no  doubt  aggravated  by  the  frequent  excitation  and  stimulation. 

The  local  symptoms  are  vague  and  insignificant.  There  may  be 
noticed  on  close  inspection  a  slight  redness  of  the  parts,  and  the  pre- 
puce or  the  nymphse  may  be  swollen. 

The  occurrence  of  frequent  erections  is  a  very  suggestive  sign 
of  masturbation  and  I  have  found  this  symptom  fairly  constant  in 
a  number  of  the  cases  under  my  observation.  After  the  fifth  ^ear 
the  habit  is  usually  practised  manually,  and  these  children  often 
exhibit  the  so-called  "tell-tale"  signs  of  mastiu-bation,  such  as  sunken 
eyes,  with  dilated  pupils  and  dark  rings  around  them,  palpitation 
-of  the  heart,  headache,  and  constant  fatigue,  but  in  most  instances 
these  are  merely  symptoms  of  neurasthenia. 

When  practised  persistently,  and  to  great  excess  after  infancy, 
masturbation  is  highly  suggestive  of  imbecility,  or  at  least  a  certain 
amount  of  mental  deficiency,  and  in  these  cases  the  child's  physical 
condition  may  become  greatly  impaired;  but  too  many  dire  effects 
have  been  attributed  as  results  of  this  habit,  for  if  carried  on  to  a 
mild  degree,  unless  one  catches  the  child  in  the  act,  it  may  escape 
the  notice  of  both  parents  and  physician,  so  slight  are  the  signs  and 
symptoms. 

These  children  are  usually  languid  and  shy  to  a  greater  or  lesser 
extent,  showing  little  or  no  disposition  to  play  the  usual  games  of 
childhood,  and  are  often  backward  in  school,  peevish,  and  irritable. 
By  far  the  greatest  harm  done  by  masturbation  is  the  effect  on  the 
moral  nature  of  the  child  who  practises  it  and  is  conscious  of  wTong- 
doing,  for  from  then  on  it  is  the  mind  which  suffers  and  not  the  body. 


584  DISEASES  OF   THE  GEN  I  TO-URINARY  SYSTEM 

Moral  degeneration  in  one  child  just  at  the  imitative  age  also 
results  quickly  in  spreading  the  habit,  and  the  harmful  effects  on  his 
or  her  associates  are  far-reaching  and  unlimited.  As  soon  as  the  child 
who  masturbates  comes  to  the  realization  that  the  act  is  wrong,  it 
naturally  practises  it  in  secret,  which  produces  that  air  of  seclusive- 
ness  and  the  guilty  expression  so  characteristic  of  the  masturbator. 

Prognosis. — The  prognosis  is  favorable,  but  the  duration  of  the  habit 
depends  greatly  on  the  age  of  the  child,  and  to  a  lesser  extent  upon 
the  length  of  time  it  has  been  practised,  and  upon  the  child's  mental 
and  physical  condition.  In  infancy  spontaneous  recovery  usually 
takes  place  before  the  second  year,  but  the  duration  of  the  habit 
may  be  appreciably  shortened  by  appropriate  treatment.  Older 
children  are  not  so  amenable  to  treatment  and  some  of  these  cases 
are  most  obstinate  and  persistent  in  spite  of  rigid  discipline  and 
thorough  care,  but  unless  great  mental  deficiency  or  imbecility  is  to 
be  reckoned  with,  no  case  should  be  regarded  as  intractable. 

Treatment. — Prophylaxis  with  regard  to  masturbation  is  very 
important,  for  prevention  of  the  habit  is  far  easier  than  the  cure. 
Of  prime  importance  is  careful  attention  to  cleanliness  of  the  genitalia 
and  avoidance  of  all  sources  of  irritation  to  the  parts.  Male  infants 
should  have  the  glans  exposed  and  cleansed  each  day  at  the  time  the 
bath  is  given,  and  if  phimosis  is  present,  or  the  prepuce  is  greatly 
elongated,  circumcision  is  advisable. 

In  little  girls  the  same  amount  of  care  and  attention  is  required 
to  prevent  irritation  around  the  clitoris.  Older  children  should  be 
trained  never  to  touch  the  genitalia  and  should  be  carefully  watched 
to  see  that  these  instructions  are  carried  out.  Masturbation  is  usually 
practised  just  after  the  child  is  put  to  bed,  or  before  arising  in  the 
morning,  and  if  the  parents  are  told  this  they  may  be  able  to  restrain 
the  habit  to  a  great  extent  themselves,  by  not  allowing  to  child  to 
lie  awake  alone  before  it  goes  to  sleep  or  just  after  it  awakens. 

Children  must  never  be  allowed  to  sleep  together  when  visiting 
each  other,  and  even  within  the  family  circle  the  juvenile  members 
should  each  have  a  separate  bed  wherever  possible.  Parents  should 
investigate  carefully  the  morals  of  their  children's  playmates,  and 
when  children  attain  the  age  of  reason  and  understanding,  explain 
to  them  the  M'hole  subject  of  sex  hygiene  rather  than  have  them 
accept  the  perverted  and  misconstrued  conception  of  these  matters 
which  they  are  sure  to  learn  from  their  associates. 

When  the  habit  is  once  established  in  infancy  there  are  two  lines 
of  procedure  which  must  be  followed  out  in  order  to  break  it  up — 
removal  of  the  cause,  and  forcible  restraint  to  interrupt  the  practice 
immediately.  In  many  instances  removal  of  the  cause  is  sufficient 
in  itself  to  effect  a  cure,  but  the  child  should  be  watched  closely  for 
some  time  afterward  and  any  suspicious  movements  should  be 
discouraged.  The  method  of  restraining  the  infant  from  mastur- 
bation depends,  of  course,  upon  the  particular  way  in  which  the 
act  is  performed. 


MASTURBATION  585 

If  possible,  a  nurse  should  be  detailed  upon  each  case  to  watch 
the  child  continually  and  forcibly  prevent  the  accomplishment  of 
the  act  by  taking  the  chilcl  up  out  of  bed  and  holding  it  each  time 
the  movements  begin.  Since  it  is  very  inconvenient  and  often 
impossible  to  have  a  child  under  direct  observation  for  twenty-four 
hours  each  da}',  mechanical  appliances  are  employed,  which  many 
times  are  practical  and  of  great  service.  These  appliances  may  be 
improvised  at  home  or  purchased  from  any  surgical  instrument  maker, 
and  for  the  most  part  comprise  triangular  splints  which  are  placed 
between  the  legs  and  adjusted  so  that  the  base  of  the  triangle  keeps 
the  knees  apart,  thus  preventing  thigh  friction,  and  knee  braces 
have  also  been  devised  for  the  same  purpose. 

I  have  many  times  obtained  excellent  results  by  instructing  the 
nurse  to  fasten  one  foot  to  one  corner  of  the  crib  and  the  other  foot 
to  the  opposite  corner  and  keep  the  thighs  separated  in  this  manner. 
If  manual  masturbation  is  practised,  the  hands  may  be  incapacitated 
by  having  the  child  wear  a  sleeveless  gown  or  tying  each  hand  to 
opposite  sides  of  the  crib. 

In  older  children,  forcible  restraint  is  a  much  more  difficult  matter, 
and  if  punishment  is  given  for  each  offense  there  quickly  develops 
a  tendency  to  perform  the  act  in  secret  which  renders  these  cases 
all  the  more  difficult  to  treat.  Moral  suasion  is  often  very  effectual 
where  secret  indulgence  is  practised,  if  the  patient's  confidence  is 
gained.  Those  in  attendance  upon  such  a  case  should  employ  the 
most  tactful  and  diplomatic  methods,  thereb}^  impressing  the  patient 
with  their  desire  to  help  in  breaking  the  habit  rather  than  to  accuse 
him  of  a  shameful  practice  continually. 

Moral  cleanliness  should  be  pointed  out  to  these  children  as  a  virtue 
to  be  sought  for  and  attained,  and  an  attempt  should  be  made  to 
substitute  healthy  outdoor  sports  for  the  lewd,  sexual  excitement 
aroused  in  the  mind  of  a  child  who  is  the  victim  of  the  habit. 

I  have  rarely  seen  these  children  benefited  by  the  administration  of 
drugs  and  do  not  advise  their  use,  since  the  amount  of  any  drug 
sufficient  to  inhibit  the  act  is  often  so  great  as  to  make  the  child 
stuporous.  In  infancy,  however,  the  administration  three  times  a  day 
of  bromide  of  sodium  in  2-grain  doses,  or  tincture  of  belladonna  in 
1-drop  doses,  will  sometimes  quiet  the  patient  and  aid  materially  in 
the  general  treatment  of  the  case.  The  child  who  masturbates  should 
be  treated  physically  as  well  as  trained  mentally. 

A  change  of  climate,  associations,  playmates,  nurses,  and  en^dron- 
ment  is  of  tremendous  advantage  when  possible,  since  it  supplies 
new  material  for  the  child's  attention  and  engages  his  interest  so 
completely  that  the  habit  may  be  unconsciously  neglected.  The 
diet  should  be  carefully  regulated  so  that  an  increased  amount  of 
nutrition  is  afforded  without  undue  tax  upon  the  digestive  system. 
Medicinal  tonics  such  as  arsenic,  cod-liver  oil,  or  various  preparations 
of  iron  are  undoubtedly  of  value,  but  may  be  disregarded  entirely 
in  treatment  if  cold  bathing  and  plenty  of  outdoor  exercise  are 
indulged  in. 


CHAPTER  XX. 
DISEASES  OF  THE  SKIN. 

In  no  other  organ  of  the  body  is  a  healthful  condition  during  childhood 
of  greater  importance  than  in  the  skin,  which  is  intimately  concerned 
in  two  vital  processes — excretion  and  heat  radiation.  While  the 
proper  functionating  of  the  skin  is  so  highly  necessary  to  the  child, 
yet  the  skin  is  at  the  same  time  extremely  tender  and  delicate,  therefore 
much  more  susceptible  to  disease  than  in  the  adult.  It  is  very  sensitive 
in  its  response  to  systemic  conditions,  and  normal,  healthy  skin  in  an 
infant  is  an  indication  of  the  efficiency  of  the  other  vital  functions  of 
the  body. 

Infection  of  an  infant's  skin  m.ay  occur  without  any  appreciable 
break  in  its  continuity;  mere  stretching  will  traumatize  it.  Neglect 
of  the  skin,  especially  during  infancy,  is  quickly  followed  by  inflamm.a- 
tion  and  infection.  Clothing,  if  excessive,  will  cause  sudamina,  and 
even  eczema.  Flannel  and  wool  are  irritating,  and  should  not  be 
worn  next  to  the  skin.  Excretions,  such  as  sweat,  urine,  and  feces,  if 
allowed  to  remain  in  contact  with  the  skin,  quickly  give  rise  to  inflam- 
mation, therefore  special  attention  should  be  given  to  the  cleanliness 
of  the  infant.  Bathing  very  young  children,  at  least  twice  daily,  is 
necessary  to  secure  the  proper  function  and  healthy  condition  of  the 
skin. 

The  common  lesions  of  the  skin  during  childhood  are  lichen,  eczema, 
impetigo,  ecthyma,  furuncular  eruptions,  herpes,  and  erythema.  Less 
frequently  we  see  psoriasis,  tinea,  alopecia,  and  molluscum  contagio- 
sum.  Occasionally,  cases  of  pem.phigus,  keloid,  and  erysipelas  are 
observed.  In  infancy,  congenital  disorders,  nevi,  ichthyosis,  sclerema 
neonatorum,  eczema,  and,  particularly,  pustular  infections  appear. 
At  puberty,  acne,  seborrheic  dermatitis,  and  other  disturbances  of 
the  sebaceous  glands  occur.  Inflam.m.ations  of  the  skin,  because  of  its 
delicate  structure,  are,  in  younger  children,  usually  acute  in  type. 

ECZEMA. 

The  usual  types  of  eczema  in  children  are  the  vesicular  and  pustular 
form.s,  or  a  combination  of  the  two.  Although  eczem.a  is  of  an  acute 
type,  its  course  is  frequently  chronic,  and  it  m.ay  last  several  years. 

Etiology. — The  most  comm.on  causes  of  eczema  in  infants  and  young 
children  are  soap,  hard  water,  rough  clothing,  and  pathological  secre- 
tions. The  presence  of  toxins  in  the  blood,  due  to  deficient  elimination, 
imperfect  metabolism  and  assimilation  of  food,  caused  by  improper 


ECZEMA  587 

or  irregular  feeding,  are  important  systemic  causes.  Local  infection 
of  the  skin  by  pyogenic  organisms  is  more  common  during  childhood 
than  at  any  other  time  of  life,  and  may  produce  eczema. 

In  children  eczema  most  frequently  involves  the  face,  head,  ears, 
the  creases  of  the  neck,  axilla,  groin,  scrotal,  and  anal  regions.  It  is 
often  associated  with  scabies  and  pediculi,  as  rubbing  and  scratching 
because  of  itching  from  any  cause  may  give  rise  to  eczema.  More 
than  one-third  of  the  cases  of  eczema  seen  in  children  occur  during  the 
first  year,  and  most  of  these  before  the  fifth  month. 

Symptoms. — Itching  is  the  chief  subjective  symptom,  and  the  one 
most  difficult  to  relieve.  The  scratching  which  follows  results  in  the 
rapid  spread  of  the  disease  and  the  form.ation  of  thick  crusts  composed 
of  blood  and  pus.  The  skin  surrounding  the  encrusted  area  is  reddened, 
thickened,  and  inflamed,  with  scaling  at  the  m.argins. 

In  children  pediculi  are  associated  with  eczem.a  of  the  scalp  m.ore 
frequently  than  in  infants,  and  they  tend  to  aggravate  the  condition 
by  increasing  the  severity  of  the  itching. 

Diagnosis. — The  diagnosis  of  typical  cases  of  eczema  in  children  is 
easy,  but  it  must  be  differentiated  from  erysipelas,  scabies,  psoriasis, 
impetigo,  and  syphilis.  Erysipelas  is  distinguished  by  its  rapidly 
spreading  margin  and  by  the  high  fever  which  accompanies  it. 

Scabies  may  occur  with  eczem.a,  -but  should  not  be  confused  with  it, 
the  distribution  being  different.  The  itching  is  worse  at  night.  The 
parasites  may  be  demonstrated  in  scabies,  and  there  is  usually  a  history 
of  scabies  in  other  members  of  the  family. 

Psoriasis  is  essentially  dry,  while  the  eczema  of  children  is  usually 
moist.  The  elbows  and  knees  and  extensor  surfaces  are  affected  in 
psoriasis,  while  the  flexor  surfaces  are  the  usual  sites  of  eczema.  The 
silvery  scales  of  psoriasis  are  characteristic,  and  can  be  dem.onstrated. 

Syphilides  show  no  tendency  to  itch,  and  the  lesions  are  not  as 
acutely  inflammatory  as  in  eczema.  There  are  usually  other  symptoms 
and  signs  of  syphilis  in  the  infant  or  child. 

Treatment. — Success  in  the  treatment  of  eczema  is  only  attained 
after  a  thorough  search  for,  and  removal  of  the  cause,  and  the  persistent 
application  of  m.easures  to  relieve  the  condition.  Regulation  of  the 
diet  is,  perhaps,  the  m.ost  important  factor  in  treatm.ent.  The  bowels 
should  be  thoroughly  cleaned  out,  and  thereafter  kept  regular.  Alka- 
line diuretics  are  also  indicated  to  relieve  the  hyperacidity  of  the  urine. 

Aside  from  these  general  measures,  there  is  no  internal  medication 
of  specific  value.  Local  treatment  is  directed  to  the  relief  of  itching 
and  the  prevention  of  scratching.  If  the  eczema  be  of  a  mild  degree,  a 
dusting  powder  of  zinc  stearate,  zinc  oxide,  or  boric  acid  m.ay  be  used 
after  thorough  cleansing  of  the  skin,  which,  however,  should  never  be 
attained  by  the  use  of  soap.  When  water  is  used,  it  should  preferably 
be  boiled  first,  and  should  contain  boric  acid  or  a  solution  of  bran. 

In  more  severe  cases,  boric  acid  ointment  (1  dram  to  the  ounce  of 
petrolatum)  may  be  daubed  on  the  eczem.atous  area  with  a  piece 
of  cotton'  instead  of  cleansing  the  part  with  water.     For  the  relief  of 


588  DISEASES  OF   THE  SKIN 

itching,  phenol  may  be  added,  using  5  grains  to  tlie  ounce  of  ointment. 
Lotions  containing  zinc  oxide  and  hme-water,  or  calamine  lotions,  are 
very  soothing  and  beneficial.  In  cases  \yith  much  moisture,  a  solution 
of  silver  nitrate,  one-half  of  1  per  cent.,  may  be  used  to  advantage. 

Subacute  eczemas  in  children  are  apt  to  appear  after  infancy,  and 
call  for  mild  stimulation  with  an  ointment  containing  resorcin,  zinc 
oxide,  and  bismuth.  In  chronic  cases,  stimulation  should  be  somewhat 
stronger,  and  for  this  sulphur,  resorcin,  creosote  ointment,  Lassar 
paste,  or  tar  ointment  is  advisable. 

All  dressings  m.ust  be  firmly  secured,  and  in  infants  and  young 
children,  especially,  this  is  very  difficult.  In  eczema  of  the  face  and 
scalp,  a  mask  which  fits  well  down  over  the  neck  is  excellent,  as  it  not 
only  insures  the  continuous  application  of  the  ointment,  but  prevents 
scratching.  A  good  plan  for  preventing  scratching  of  any  affected 
part  is  to  put  a  straight  splint  on  each  arm,  thus  m.aking  flexion  of 
the  elbow  impossible. 

When  eczema  of  the  scalp  is  complicated  by  pediculosis,  as  is  fre- 
quently the  case,  the  crusts  resulting  from  persistent  scratching  are 
very  hard  and  thick,  and  must  be  removed  before  the  application  of 
ointments,  but  m.ust  be  remo^'ed  carefully,  or  the  condition  will  be 
aggravated.  The  best  method  is  to  apply  olive  or  cod-liver  oil,  con- 
taining 1  dram  of  phenol  and  2  drams  of  balsam  of  Peru  to  the  ounce. 
After  several  hours  of  soaking,  the  crust  may  be  easily  taken  off 
with  the  aid  of  warm  water,  and  this  should  be  followed  by  the  applica- 
tion of  the  ointment  or  lotion  desired.  The  scalp  should  be  treated 
with  petroleum,  bichloride  solution,  or  alcohol  for  the  removal  of 
nits  and  pediculi. 

The  following  prescriptions  have  been  employed  with  excellent 
reSults : 

Acute  Eczema. 

I^ — Phenolis .      .      .      gr.  v 

Calaminse -3.1 

Ung.  zinci  oxidi ovij — M. 

Subacute  Eczema. 

I^ — Acidi  salicylicj gr.  xx 

Pulv.  amyli, 

Pulv.  zinci  oxidi aa      oiJ 

Petrolati         5iv— M. 

Che  )Xic  Eczema. 

I^ — Ung.  picis  liquidse oj 

Pulv.  zinci  oxidi oiJ 

Ung.  aquae  rosse oiv — M. 


URTICARIA   (NETTLE  RASH:   HIVES). 

Urticaria  in  children  differs  slightly  from  the  form  seen  in  adults. 
It  is  characterized  by  a  multiform  eruption  of  whitish,  pinkish,  or 
reddish  color,  which  suddenly  appears,  and  as  suddenly  disappears, 
showing  a  marked  tendency  to  recurrence.     This  eruption  is  accom- 


ICHTHYOSIS  589 

panied  by  painful,  pricking,  and  tingling  sensations.  Papules  are 
most  abundant  in  those  forms  in  which  the  attacks  last  for  weeks, 
while  wheals  appear  in  those  of  short  duration.  In  severe  cases, 
there  m.ay  be  vesicles,  vesicopustules,  and  pustules.  The  eruption  is 
most  intense  on  the  trunk;  but  the  lesions  shift  about,  and  when 
they  appear  on  the  face  may  be  c^uite  disfiguring. 

Etiology. — So  frequently  is  gastro-intestinal  disorder  a  cause  of 
urticaria  that  the  latter  is  now  considered  to  be  a  cutaneous  mani- 
festation of  toxemia  caused  by  faulty  digestion  and  metabolism. 
The  mere  presence  of  indigestible  food  in  the  stomach  of  an  infant 
may  cause  urticaria,  and  certain  cases  may  be  traced  to  intestinal 
parasites.  Sea  food,  canned  meats  and  vegetables,  pastry,  confec- 
tionery, and  certain  fruits,  particularly  berries,  are  liable  to  cause 
urticaria. 

A  few  cases  may  be  traced  to  the  bites  of  insects,  giving  rise  to  a 
localized  area  of  urticaria  which  quickly  spreads.  Sudden  emotion  or 
excitement  may  bring  on  an  attack  in  a  susceptible  child.  Certain 
drugs,  among  which  are  quinin,  arsenic,  the  salicylates,  and  opium, 
also  the  serums,  will  produce  urticaria  in  some  individuals. 

Symptoms. — The  local  symptoms  are  the  severe  burning  and  intense 
itching  which  accompany  the  eruption.  In  children,  an  urticarial 
attack  may  often  be  preceded  by  gastric  and  nervous  disturbances  and 
a  rise  in  temperature. 

Diagnosis. — The  diagnosis  is  easy,  and  is  sometimes  made  by  the 
parents.  The  rapidity  of  the  onset  and  appearance  of  the  eruption, 
and  the  severe  itching  which  accompanies  it,  leave  little  doubt  as  to 
the  afiFection.     Usually  there  is  a  history  of  preceding  attacks. 

Treatment. — The  chief  considerations  in  treatment  are  restriction 
of  the  diet  and  regulation  of  the  feeding.  An  initial  purge  is  followed 
by  light  diet,  free  from  all  irritating  foods.  Alkaline  waters  internally 
and  alkaline  baths  are  very  beneficial. 

The  administration  of  codein  is  sometimes  necessary  to  quiet  the 
nervousness  produced  by  the  itching.  The  skin  may  be  sponged 
with  a  lotion  containing  from  0.5  to  1  per  cent,  of  either  phenol, 
dilute  hydrocyanic  acid,  or  menthol.  Instant  relief  may  often  be 
obtained  by  the  use  of  the  prescription  below: 

I^ — Phenolis 5i.i 

Glycerinse fgj 

Aquge q.  s.  f  5xvj — M. 

Sig. — Use  as  a  spray. 

ICHTHYOSIS. 

Ichthyosis  is  a  congenital  disease  of  the  skin  characterized  by  a 
hardness  and  dryness,  also  by  a  scaliness  from,  which  it  gets  its  name 
of  fish-skin  disease.  In  som.e  cases  the  skin  is  much  thickened  and 
furrowed,  and  resembles  a  suit  of  arm.or.  This  severe  degree  of 
ichthyosis  is  rarely  seen;  the  children  who  are  born  with  the  disease 
so  well  developed  are  generally  monsters,  and  do  not  live.  In  the 
common  type,  ichthyosis  is  not  incompatible  with  life. 


590  DISEASES  OF   THE  SKIN 

Etiology. — The  cause  of  ichthyosis  is  unknown. 

Symptoms. — The  ordinary  type  of  ichthyosis  usually  appears  during 
the  second  year.  The  skin  becom.es  dry,  wrinkled,  papery,  and 
scaly.  The  whole  body  m.ay  be  involved,  but  the  disease  is  more 
severe  on  the  outer  surface  of  the  arms  and  legs,  the  general  health 
remaining  unaffected. 

Diagnosis. — Ichthyosis  has  such  typical  characteristics  that  ■  it  is 
rarely  mistaken  for  any  other  affection  of  the  skin,  the  absence  of 
inflam.mation  being,  perhaps,  its  m.ost  distinctive  feature. 

Prognosis. — There  is  no  cure  for  the  disease,  and  in  authentic  cases 
no  recoveries  have  ever  been  reported.  The  condition  of  the  skin 
may  greatly  im.pro^'e  under  careful,  proper,  and  persistent  treatm.ent. 

Treatment. — Children  with  ichthyosis  are  greatly  benefited  by  res- 
idence in  a  moist,  warm  climate,  and  this  should  always  be  strongly 
advised.  Frequent  bathing  in  alkaline  waters,  followed  by  the  appli- 
cation of  an  oily  substance,  will  prevent  the  skin  from  becoming 
extrem.ely  dry  and  rough.  Almond  oil,  cod-liver  oil,  cottonseed  or 
olive  oil  may  be  used,  and  to  any  one  of  these  may  be  added  salicylic 
acid  or  resorcin.  No  internal  m.edication  seems  to  be  of  much  value, 
although  thyroid  extract  is  recom.m.ended  by  various  authorities.  An 
ointment  to  keep  the  skin  moist  and  smooth  may  be  prescribed  as 
follows : 

I^ — Acidi  salicylici gr.  xv 

Glycerinse lUxxx 

Lanolin ■  3ij 

Resorcin gr.  xl 

Adipis  benzoate 5vi 

Ung.  paraffin gij — M. 

INTERTRIGO. 

Intertrigo  is  a  very  common  disease  during  childhood,  especially 
in  infants.  It  is  a  chafing  and  rubbing  off  of  the  superficial  skin, 
which  has  been  macerated  by  constant  moisture  of  the  parts.  It 
occurs  in  the  natiu-al  folds  of  the  skin,  and  is  m.ost  frequently  seen 
on  the  buttocks  and  scrotum,  in  the  groin,  and  axilla. 

Etiology. — Maceration  of  the  skin  which  precedes  the  chafing  is 
caused  by  the  action  of  highly  acid  urine,  feces,  or  even  perspiration. 
Intertrigo  may  be  found  in  any  parts  of  the  bod}'  where  two  skin 
surfaces  rub  against  each  other  during  movement.  The  superficial 
epidermis  comes  away  as  a  result  of  this  chafing  and  leaves  a  moist,  red 
surface,  which  soon  becomes  infected. 

Symptoms. — The  lesions  vary  in  degree  from  mere  erythem.a  to  an 
encrusted  area  of  infected  skin,  which  is  actively  inflam.ed,  painful, 
and  tender.  There  are  usually  no  constitutional  symptoms,  the 
cause  being  local. 

Diagnosis. — The  diagnosis  is  easy,  the  only  other  skin  lesion  sim.u- 
lating  it  closely  being  cutaneous  syphilides  in  the  natural  folds  of  the 
body.     In  a  given  case,  however,  this  syphilitic  eruption  will  usually 


IMPETIGO   CONTAGIOSA  -  591 

be  found  in  other  locations  and  concomitant  symptoms,  such  as 
snuffles  or  hoarseness,  may  be  present.  A  Wassermann  reaction  will 
aid  m.aterially  in  a  doubtful  case. 

Treatment. — Prophylaxis  is  very  important  and  also  practical  in 
intertrigo.  Strict  cleanliness  must  be  maintained  without  the  too 
frequent  use  of  soap.  The  buttocks  should  be  sponged  oft'  with  warm 
water  after  each  evacuation  of  the  bowels,  and  the  napkins  should 
always  be  fresh  and  clean.  The  urine  may  be  highly  acid,  and  if 
allowed  to  remain  on  the  skin,  or,  if  napkins  are  merely  dried  and 
reapplied,  the  intertrigo  will  be  aggravated. 

After  washing  off  the  parts  they  should  be  dried  carefully,  and  boric 
acid  powder,  talc,  or  zinc  stearate  should  be  dusted  on.  If  there  is  a 
tendency  to  chafing  of  opposing  skin  surfaces,  they  may  be  kept  apart 
by  wads  of  absorbent  cotton.  The  digestive  system  should  be  investi- 
gated with  a  view  of  correcting  any  acidity  in  the  discharges,  and  the 
urine  should  be  tested  for  hyperacidity.  In  the  early  stages  intertrigo 
usually  yields  readily  to  the  application  of  the  powder  which  follows: 

I^ — Zinci  oxidi  piilv 3ss 

Camphorse  pulv 5iss 

Amyli  pulv Bj — M. 

Sig. — Dusting  powder. 

IMPETIGO    CONTAGIOSA. 

Impetigo  contagiosa  is  a  highly  contagious  and  auto-inoculable  skin 
disease,  occurring  most  frequently  am.ong  the  children  of  the  poor. 
Epidemics  are  often  observed  in  institutions.  The  disease  is  caused 
by  infection  of  the  skin  with  the  staphylococcus.  An  attack  lasts 
from  ten  to  fourteen  days,  but  the  child  m.ay  suffer  with  impetigo  for 
weeks,  kept  up  by  auto-inoculation. 

These  lesions  are  m.ost  com.m.only  seen  on  the  face,  about  the  nostrils 
and  corners  of  the  mouth,  also  on  the  hands,  and  m.ay  extend  to  any 
part  of  the  body.  They  first  appear  as  vesicles,  which  vary  in  size 
from  that  of  a  pin  head  to  the  diameter  of  a  five  cent  piece,  and  are 
flattened  on  top.  The  vesicles  soon  becom.e  pustules,  which  coalesce 
and  rupture,  and  result  in  the  formation  of  grayish-yellow  crusts. 
The  crusts  appear  as  though  they  were  m.erely  stuck  on  the  skin,  but 
are  usually  attached  to  the  hairs  and,  if  rem.oved,  leave  a  raw,  bleeding 
surface.     There  is  no  itching,  "and  the  lesions  leave  no  scar. 

The  characteristic  features  of  impetigo  contagiosa  are  quite  distinct, 
and  the  diagnosis  is  made  on  the  superficial  appearance  of  the  lesions, 
their  distribution,  the  absence  of  itching,  with  evidence  of  auto- 
inoculation  or  a  history  of  contagion.  By  these  definite  features  it 
can  readily  be  distinguished  from  pustular  eczema,  varicella,  and 
scabies. 

Treatment. — It  it  were  not  for  the  danger  of  auto-inoculation  in 
children,  the  lesions  could  safely  be  allowed  to  heal  spontaneously. 
They  should  be  kept  clean  and  healed  as  rapidly  as  possible,  however, 


592  DISEASES  OF   THE  SKIN 

to  prevent  their  spreading.  The  crusts  may  first  be  softened  by  a 
bland  oil,  and  then  washed  off  with  green  soap  and  warm  water. 
After  the  crusts  are  removed  an  ointment  containing  15  grains  of 
sulphur  to  one  ounce  of  Lassar's  paste  should  be  applied.  The  gen- 
eral health  of  these  children  is  usually  poor,  and  should  be  improved 
by  regulation  of  the  diet,  good  hygiene,  and  the  administration  of 
tonics,  such  as  cod-liver  oil  or  iron.  The  preparation  appended  below 
has  been  found  invaluable  in  the  treatment  of  impetigo. 

I^ — Hydrargyri  ammoDiata gr.  xx 

Petrolati 5J — M. 

FURUNCULOSIS. 

Furunculosis,  in  which  multiple  boils  appear  all  over  the  body,  or 
successive  crops  in  certain  regions  of  the  body,  is  quite  common  during 
childhood.  The  boils  are  the  result  of  a  deep-seated  infection  of  the 
skin,  most  frequently  by  the  Staphylococcus  pyogenes  aureus,  which 
attacks  children  whose  vitality  is  low  from  malnutrition  or  debilitating 
disease.  It  rarely  occurs  in  the  very  young,  but  may  follow  prickly 
heat  in  infancy.  It  is  quite  common  to  see  a  child's  scalp,  as  well 
as  "the  rest  of  the  body,  covered  with  boils. 

These  boils  vary  in  size,  burrow  deeply,  are  acutely  inflamed,  and 
^"ery  tender  and  painful.  They  terminate  in  suppuration  with  rupture, 
and  the  pus  which  is  discharged  may  then  infect  other  areas  of  skin, 
if  there  be  any  abrasion.  Constitutional  symptoms  sometimes  appear, 
and  the  child  is  restless,  loses  weight  and  strength,  and  may  have 
slight  fever. 

Treatment. — The  local  treatment  of  the  individual  boil  depends  upon 
the  stage  of  inflammation  it  has  reached.  Suppuration  may  often  be 
aborted  by  the  immction  of  10  to  20  per  cent,  ichthyol  ointment  over 
the  inflamed  area.  If  suppuration  has  taken  place  the  boil  should  be 
lanced,  and  the  pus  gently  squeezed  out.  The  cavity  may  then  be 
wiped  out  with  carbolic  acid  on  the  end  of  an  applicator.  In  using 
pure  carbolic  acid  care  should  be  taken  not  to  injure  the  surrounding 
skin,  and,  unless  perfect  control  of  the  patient  is  assured,  it  is  wiser 
to  use  hydrogen  peroxide. 

Vaccine  therapy  is  very  effecti^"e  both  in  curing  and  preventing 
attacks.  Both  autogenous  and  stock  vaccines  are  used  with  equal 
success.  In  addition  to  these  measures  the  child's  general  health 
should  be  built  up  by  change  of  environment,  with  country  or  seashore 
life,  which  will  do  much  to  prevent  future  attacks.  The  diet  frequently 
needs  regulation,  and  tonics  are  also  indicated. 

One  or  two  applications  of  the  following  preparation  will  hasten 
the  cure  of  a  furuncle  by  rapidly  bringing  the  pus  to  a  focus. 

I^ — Acidi  salicyli 3ij 

Emp.  saponis gij 

Emp.  diachj"li 5J — ^I- 

Sig — Spread  on  cotton  cloth  and  apply  over  the  boil. 


SEBORRHEA  593 


MILIARIA. 


Miliaria  is  a  disease  of  infancy  and  childhood,  which  results  from 
the  clogging  of  the  sweat  ducts,  and  is  most  common  during  hot 
weather.  It  may,  or  may  not,  be  inflammatory.  The  non-inflam- 
matory form  is  called  sudamina.  The  lesions  consist  of  papules  of 
pin-head  size,  surmounted  by  vesicles  which  contain  pure  sweat. 
They  are  most  abundant  on  the  neck,  chest,  abdomen,  and  back. 

There  may  be  a  slight  erythema  between  the  papules,  and  there  is 
usually  itching,  also  a  burning  sensation.  An  attack  subsides  in  the 
course  of  a  week;  but,  unless  precautions  are  taken,  there  may  be 
several  outbreaks  during  the  summer.  Very  slight  desquamation 
follows  the  rupture  of  the  vesicles. 

Treatment. — Frequent  bathing,  the  wearing  of  light  outer  garments, 
and  of  silk  and  linen-mesh  underwear  are  important  prophylactic 
measures.  Locally,  boric  acid  solution,  bran  baths,  or  alkaline  lotions 
are  soothing.  Dusting  powders  of  boric  acid,  zinc  stearate,  or  starch 
will  dry  up  the  vesicles.  A  sojourn  at  the  seashore  with  sea-bathing 
will  hasten  the  cure. 

ERYTHEMA   MULTIFORME. 

Erythema  multiforme  is  characterized  by  the  appearance  of  lesions  of 
m.any  types,  from  simple  erythema  to  papules,  or  even  tubercles. 
The  papular  form  of  eruption  is,  perhaps,  the  m.ost  common  in  children. 
The  process  is  acutely  inflammatory,  but,  as  a  rule,  there  are  no  sub- 
jective symptoms.  The  eruption  may  be  ushered  in  by  a  feeling  of 
malaise  or  vague  rheumatic  pains.  It  disappears  as  suddenly  as  it 
com.es,  lasting  usually  a  week  or  ten  days. 

The  eruption  may  appear  on  any  part  of  the  body,  but  is  seen  most 
frequently  on  the  hands,  arm.s,  feet,  and  legs.  There  is  usually  some 
intestinal  derangement,  auto-intoxication,  or  ptomain  poisoning,  to 
which  it  may  be  attributed. 

Treatment. — The  child  should  receive  at  the  onset  of  the  attack 
a  course  of  calomel,  followed  by  castor  oil.  Quinine  and  the  salicylates 
should  be  given  in  sro.all  doses.  A  lotion  containing  1  per  cent,  of 
phenol,  or  a  dusting  powder,  should  be  used  locally.  The  diet  should 
be  investigated  in  every  case  and  carefully  regulated. 

SEBORRHEA. 

Seborrhea  is  marked  by  the  appearance  of  crusts  composed  of  the 
secretions  from  overactive  sweat  glands,  and  is  commonly  known  as 
the  "milk  crust."  It  appears  most  frequently  on  the  scalp,  but  may 
also  occur  on  the  forehead  in  infants.  The  crust  is  grayish  yellow  in 
color,  shows  a  tendency  to  scaling,  and  is  firmly  adherent  to  the  skin 
which,  however,  is  not  inflamed.  Seborrhea  is  a  skin  disease  which 
attacks  poorly  nourished  children,  and  is  roost  common  in  infancy  and 
at  puberty. 
38 


594  DISEASES  OF   THE  SKIN 

Treatment. — The  crusts  should  be  softened  by  applications  of  warm, 
olive  oil  or  an  ointm.ent  of  petrolatum  containing  salicylic  acid,  15 
grains  to  1  ounce.  They  m.ay  then  be  washed  off  with  warm  water 
and  Castile  soap,  and  an  ointm.ent  containing  10  to  20  per  cent,  of 
sulphur  should  be  rubbed  into  the  scalp.  The  health  is  usually 
poor,  and  any  existing  constitutional  disorders  should  be  remedied 
in  order  to  improve  the  child's  general  condition. 

PSORIASIS. 

Psoriasis  is  quite  a  common  skin  disease  during  childhood,  and 
occurs  in  apparently  healthy  children.  Lesions  may  be  found  on 
any  part  of  the  body,  but  are  most  com.m.on  on  the  knees,  elbows, 
trunk,  scalp,  and  extensor  surfaces  of  the  extrem.ities.  The  eruption 
appears  in  patches,  which  are  usually  sym.m.etrical,  sharply  defined,  and 
composed  of  papules  with  silver}'  scales  at  the  sum.m.it.  The  disease 
is  essentially  dry,  but  if  the  scales  be  removed  a  few  bleeding  points 
may  be  found  underneath  them.. 

The  course  of  psoriasis  is  generally  chronic,  but  it  som.etimes 
undergoes  spontaneous  cure  during  the  summer  only  to  retm-n  in  the 
fall.  Occasionally  there  is  a  history  of  constipation,  autointoxica- 
tion, or  of  a  rheumatic  tendency.  Psoriasis  resem.bles  seborrhea,  but 
is  m.ore  widely  distributed  in  children,  not  being  confined  to  the  scalp. 
It  is  inflammatory,  and  the  scales  are  pearly  white,  while  seborrhea  is 
non-inflam.matory  and  the  scales  are  yellow  and  greasy-looking. 
Squamous  syphilides  m.ay  look  like  psoriasis,  but  the  distribution  is 
altogether  different.  Eczem.a  is  usually  m.oist  during  infancy,  and  is 
not  sharply  defined,  as  is  psoriasis. 

Treatment. — Psoriasis  m.ay  clear  up  under  treatment,  but  shows  a 
persistent  tendency  to  recur.  Applications  of  2  per  cent,  chrysarobin 
ointment  are  very  beneficial  after  the  scales  have  been  removed  by 
washing  with  warm,  water  and  Castile  soap.  Ointments  containing 
ammoniated  mercury,  20  grains  to  the  ounce,  or  tar,  2  dram.s  to  the 
ounce  m.ay  be  used.  Arsenic  should  be  given  internally  after  the 
inflam.m.atory  symptoms  have  subsided.  X-ray  treatment  gives 
splendid  results  in  som.e  cases.  Children  with  psoriasis  are  usually 
m.uch  benefited  by  seashore  life  and  salt  water  bathing.  Regulation 
of  the  diet  is  of  prime  importance.  The  following  ointment  is  often  of 
great  benefit,  if  applied  to  lesions  after  removal  of  the  scales : 

I^ — Liquoris  picis  carbonis .      .      .  3ij 

Chrysarobin gr.  x 

Hydrargyri  ammoniata ■  gr.  xxx 

Adipis  benzoate ".      .      .      .      q.  s.  ad.  gij — M. 

TINEA. 

The  two  most  common  vegetable  parasites  which  infest  children 
are  tinea  tonsuians,  or  ringworm  of  the  scalp,  and  tinea  circinata,  or 


TINEA   TONSURANS 


595 


ringworm  of  the  body.  Favus  is  so  very  rare  that  it  barely  deserves 
mention  here.  Infants  are  rarely  affected  by  tinea,  but  it  is  common  in 
older  children. 

TINEA    TONSURANS. 

Ringworm  of  the  scalp  occurs  especially  in  children.  It  is  highly 
contagious,  and  epidemics  are  not  infrequent  in  schools  and  institu- 
tions where  children  are  closely  congregated.  The  spores  of  this 
parasite  are  found  on  the  hair  shafts,  and  are  much  like  the  roe  of  fish 
in  appearance.  They  are  smaller  than  the  spores  of  the  parasite 
which  causes  ringworm  on  the  body. 


Fig.  60. — RingT\'orm  of  the  scalp.     Tinea  tonsurans. 

Symptoms. — The  eruption  may  be  preceded  by  itching  and  swelling 
of  the  scalp.  The  lesions  are  reddish,  greenish,  or  grayish-yellow 
elevated  patches,  which  appear  on  the  scalp  and  cause  the  hair  on 
the  head  to  fall  out.  The  underlying  scalp  may  become  inflamed, 
and  exude  a  yellowish  gelatinous  material.  The  hair  follicles  become 
erect,  and  give  the  scalp  a  goose-flesh  appearance.  A  few  stumps  of 
broken  hairs  are  to  be  found  on  the  bald  areas,  and  the  long  hairs 
are  loosened. 

Diagnosis. — The  diagnosis  of  tinea  tonsurans  is  made  by  micro- 
scopic examination  of  the  hair  stumps  to  which  a  drop  of  liquor 
potass8e  has  been  applied.  The  presence  of  the  spores  is  pathogno- 
monic (Fig.  60). 

Treatment. — The  hair  of  the  scalp  should  be  cut  as  short  as  possible, 
and  the  scalp  then  well  scrubbed  with  tincture  of  green  soap.  After 
thorough  cleansing,  a  1  per  cent,  solution  of  bichloride  of  mercury,  or 


596  DISEASES  OF   THE  SKIN 

a  5  per  cent,  carbolic  acid  solution  should  be  applied  to  the  scalp 
for  several  successive  nights.  Tincture  of  iodine,  painted  on  the 
scalp,  is  also  an  excellent  remedy. 

If  there  are  only  a  few  patches,  these  may  be  blistered  with  glacial 
acetic  acid,  after  which  a  parasiticide  should  be  used,  and,  in  my  experi- 
ence, an  ointment  containing  nitrate  of  mercury,  sulphur,  and  phenol 
is  most  useful.  Chronic  cases  must  be  treated  patiently  and  vigor- 
ously, since  they  are  very  stubborn  and  resist  treatment  for  months 
before  they  are  overcome.  Acute  or-  recent  cases  usually  respond  well 
to  treatment. 

The  following  has  been  found  to  be  a  most  effective  ointment: 

I^— B.  naphthol 3J 

Ol.  cadini 3ij 

Ung.  sulphur       .      .      . q.  s.  ad.      gij — -M. 

TINEA   CIRCINATA. 

Tinea  circinata,  or  ringworm  of  the  body,  is  a  much  milder  disease 
of  the  skin  than  tinea  tonsurans.  It  may  occur  on  any  part  of  the 
body,  but  is  most  common  on  the  face,  hands,  and  arms.  It  appears 
in  the  form  of  small  circular  spots,  which  spread  rapidly,  and  several 
rings  may  coalesce.  The  spores  in  tinea  circinata  are  larger  than  those 
found  in  ringworm  of  the  scalp.  There  is  usually  an  itching  sensation 
around  the  site  of  the  lesion.  Successive  applications  of  tincture  of 
iodine  or  glacial  acetic  acid  bring  about  rapid  recovery  in  a  few  days. 
The  preparations  given  below  may  be  also  used  with  equally  good 
results: 

I^ — Hydrarg.  ammoniata gr.  v 

Adipis Bj — M. 

Sig. — For  very  vouiig  children. 

Or 

I^ — Resorcini ■ gr.  xx 

Sulphur  prsecip., 

Zinci  oxide aa      3j 

Petrolati q.  s.  ad.      gij — M- 

Sig. — For  ringworm  of  the  body  in  older  children. 

HERPES. 

Herpes,  or  fever  blisters,  are  frequently  seen  during  childhood, 
usually  on  the  face.  The  eruption  consists  of  vesicles  upon  a  reddened 
base  and  containing  a  clear  fluid.  There  are  four  varieties  of  herpes: 
that  on  the  face,  herpes  facialis;  on  the  lips,  herpes  lingualis;  about 
the  genitals,  herpes  genitalis;  and  on  the  body,  herpes  zoster. 

Etiology. — Quite  frequently,  herpes  breaks  out  spontaneously,  and 
some  children  seem  predisposed  to  it.  In  the  course  of  fevers,  espe- 
cially cerebrospinal  meningitis,  malaria,  influenza,  pneumonia,  and 
tonsillitis,  herpetic  eruptions  are  quite  common. 

Symptoms. — Before  the  appearance  of  the  vesicles  there  is  usually 
a  sense  of  itching  and  burning,  followed  by  a  reddened  area  which  is 


WARTS  597 

later  the  site  of  the  eruption.  A  crop  of  tiny  vesicles  soon  appears, 
which  may  later  coalesce  and  form  one  large  crust.  The  clear  fluid 
contained  in  the  "blister"  never  becomes  purulent  unless  infected  by 
scratching,  and,  if  let  alone,  soon  dries  up.  The  attack  usually  lasts 
a  week  or  ten  days,  but  may  be  prolonged  by  the  appearance  of 
successive  crops  of  vesicles. 

Diagnosis. — ^The  diagnosis  of  herpes  is  easy,  but  some  cases  may 
suggest  eczema  or  impetigo.  Eczema  itches,  while  herpes  burns. 
The  formation  of  pus  and  crusts  is  more  common  in  eczema  than  in 
herpes.  Impetigo  is  essentially  pustular,  does  not  occur  in  single 
patches,  as  a  rule,  and  is  characterized  by  its  contagiousness  and 
auto-inoculability. 

Treatment. — The  treatment  of  herpes  should  begin  with  an  initial 
purge  and  correction  of  the  diet.  Locally,  applications  of  camphor, 
alum,  stearate  of  zinc,  or  calomel  are  beneficial.  Fowler's  solution, 
gtt.  i-ij,  three  times  a  day,  is  administered  to  children  who  show  a 
disposition  to  recurrent  outbreaks  of  the  disease. 

HERPES    ZOSTER    (SHINGLES). 

Herpes  zoster  is  quite  different  from  other  forms  of  herpes,  and 
must  be  discussed  separately.  The  eruption  is  on  the  trunk,  usually  the 
upper  half,  and  follows  the  course  of  a  nerve.     As  a  rule,  it  is  unilateral. 

Etiology. — Exposure  to  cold,  inflammation  of  the  nerve  trunks  and 
ganglia,  trauma,  and  the  season  of  the  year,  particularly  winter  and 
spring,  are  all  predisposing  factors. 

Symptoms. — Herpes  zoster  is  preceded  and  accompanied  by  neuralgic 
pain,  which  may  or  may  not  be  so  severe  as  to  require  morphine  for 
relief.  The  vesicles  vary  in  size  from  that  of  a  pin-head  to  a  split 
pea,  and,  as  a  rule,  do  not  coalesce,  but  dry  up  in  a  few  days.  Succes- 
sive crops  appear  during  the  attack,  which  usually  lasts  from  ten  to 
twenty  days. 

Diagnosis. — Before  the  eruption  is  visible  the  neuralgic  pains  of 
herpes  zoster  may  suggest  pleurodynia,  or  pleurisy.  With  the  appear- 
ance of  a  well-defined  unilateral  eruption,  following  the  course  of  a 
nerve  trunk,  the  diagnosis  is  easy. 

Treatment. — The  treatment  of  herpes  zoster  should  be  directed 
first  to  the  eruption,  which  must  be  protected  from  injury  by  a  dress- 
ing of  absorbent  cotton,  after  the.  application  of  tincture  of  benzoin, 
2  per  cent,  powdered  camphor,  or  a  10  per  cent,  ichthyol  and  collodion 
dressing.  Pain  is  occasionally  so  severe  as  to  call  for  the  administra- 
tion of  phenacetin,  heroin,  or  codeine.  Following  the  attacks  there 
may  be  a  troublesome  neuritis,  which  will  improve  with  the  use  of 
the  galvanic  current  locally,  and  salicylates  internally. 

WARTS    (VERRUCA). 

Most  warts  are  congenital  or  develop  soon  after  birth.  They  are 
composed   of  epithelium   with  a   central   axis    of   bloodvessels    and 


598  DISEASES  OF   THE  SKIN 

connective  tissne,  and  vary  in  size  from  that  of  a  split  pea  to  the 
dimensions  of  a  small  tumor.  Warts  usually  appear  on  the  hands  and 
faces  of  children  at  the  age  when  they  begin  to  crawl  around  and 
handle  everything  within  reach.  For  this  reason  they  are  believed 
to  be  contagious,  as  well  as  auto-inoculable. 

The  two  varieties  most  commonly  met  with  during  childhood  are 
the  ordinary  wart,  verruca  vulgaris,  and  the  plane  wart,  or  verruca 
planus  juvenilis.  The  common  wart  needs  no  description ;  it  is  painless, 
and,  except  for  a  disfigurement,  causes  no  trouble  except  that  it  tnay 
be  torn  and  become  infected. 

Plane  warts  are  usually  very  numerous;  they  consist  of  soft,  elevated, 
disk-like  planes,  varying  in  size  from  a  pin-head  to  a  split  pea.  They 
may  be  pale  brown  in  color,  or  the  sam.e  tint  as  the  skin.  The  dura- 
tion of  a  wart  on  the  skin  cannot  be  estimated;  they  may  come  and 
go  suddenly  or  gradually,  and  m.ay  last  for  weeks  or  months. 

Treatment. — A  favorite  method  for  the  rem.oval  of  warts  is  to  paint 
them,  on  several  successive  nights  with  salicylic  collodion,  10  per  cent, 
strength.  Glacial  acetic  acid,  containing  1  per  cent,  perchloride  of 
mercury,  applied  repeatedly  on  the  end  of  a  match-stick,  will  eradicate 
a  wart.  If  the  wart  has  a  pedicle,  or  stem,  it  may  be  snipped  off 
with  the  scissors  and  cauterized,  silver  nitrate  or  tincture  of  iodine 
being  then  applied  to  the  base.  Plane  warts  m.ay  be  treated  with 
unguentum  acidi  salicylici,  grains  xv  to  the  ounce.  Good  results  m.ay 
follow  the  use  of  sm.all  doses  of  magnesium  sulphate  three  times  a  day. 
The  children  affected  are  usually  undernourished,  and  will  be  benefited 
by  a  well-regulated  diet  and  improvement  in  their  personal  hygiene. 

ALOPECIA.  ^ 

Congenital  alopecia, "  or  absence  of  hair,  is  very  rare.  Diffuse 
alopecia  follows  febrile  or  debilitating  diseases,  and  a  patchy  alopecia 
may  result  from  inflamm.ation  or  disease  of  the  scalp.  These  forms 
of  alopecia  are  all  rather  uncom.mon,  but  alopecia  areata  is  seen  more 
frequently  in  childhood  than  in  adult  life. 

Alopecia  Areata. — In  alopecia  areata  an  irregular  surface  of  the  scalp 
is  entirely  free  from  hair,  up  to  the  clean-cut  margins  where  the  long 
hairs  are  found.  The  appearance  of  the  skin  over  this  spot  is  quite 
normal. 

Etiology. — The  exact  cause  of  alopecia  areata  is  unknown.  It 
occurs  with  greatest  frequency  in  dark-haired  children,  both  sexes 
being  affected  equally.  In  som.e  cases  there  is  an  elem.ent  of  heredity. 
In  others  there  is  evidently  a  neuropathic  taint  shown  by  a  history  of 
shock,  grief,  anxiety,  or  fright,  as,  for  instance,  from  a  lightning 
stroke. 

Reflex  irritability  from  injury  to  other  parts  of  the  body,  defective 
teeth,  and  errors  in  refraction  followed  by  severe  headache,'  may  also 
be  responsible  for  this  condition.  Syphilis  is  regarded  by  some 
authorities  as  the  most  important  etiological  factor.     Epidemics  of 


ALOPECIA 


599 


alopecia  areata  have  suggested  a  parasitic  element,  but  this  has  not 
been  supported  by  the  isolation  of  any  particular  organism. 

Symptoms. — There  are  usually  no  symptoms  preceding  the  appear- 
ance of  an  area  of  alopecia  on  the  scalp.  The  spot  appears  suddenly, 
and  the  loss  of  hair  is  complete.  The  long  hairs  at  the  margin  of  the 
bald  spot  become  loose,  and  the  spot  tends  to  grow  larger,  while  other 
spots  appear.  The  whole  scalp  may  become  involved  and  complete 
baldness  result  (Fig.  61). 


Fig.   61. — Alopecia  areata. 

Diagnosis. — Alopecia  areata  must  be  differentiated  from  ringworm; 
but  ringworm  of  the  scalp  rarely  presents  the  perfectly  bald  patches 
of  areata,  for  fungi  are  present,  and  broken  hairs  are  found  over  the 
affected  areas. 

Treatment. — Alopecia  areata  is  very  difficult  to  cure,  and  responds 
but  slowly  to  external  and  internal  medication.  The  general  health 
of  the  child  should  be  built  up,  the  nervous  system  quieted,  and  any 
associated  disease  treated.  Tonics  containing  cod-liver  oil,  strychnin, 
and  iron  should  be  administered.     Salt-water  bathing  is  very  beneficial. 

Stimulating  antiparasitic  remedies  should  be  applied  locally,  and 
of  these  alcohol,  resorcin,  turpentine,  cantharides,  and  sulphur  or 
the  mercurials  are,  perhaps,  the  best.  Hot  compresses,  used  on  the 
affected  areas  daily,  promote  the  circulation  and  favor  the  growth 
of  new  hair.  No  hope  should  be  held  out  of  cure  in  less  than  a  year; 
but,  unless  the  condition  becomes  general,  recovery  is  to  be  expected. 

A  very  serviceable  prescription  for  alopecia  areata  is  made  up  as 
follows: 

I^ — Ammonii  carbonatis gr.  xx 

Tinct.  cantharides Svj 

Aquae q.  s.  ad.      giij — M. 


600 


DISEASES  OF  THE  SKIN 


N-ffiVI. 

Nsevi  are  congenital  localized  overgrowths  of  any  element  of  the 
skin,  and  are  usually  associated  with  other  developmental  defects. 
Two  forms  of  nsevi  occur  in  children,  the  pigmented  nsevus,  or  mole, 


Fig.  C2. — Hairy  mole. 


Fig.  63. — Hairy  mole  under  treatment  with  CO2  snow. 


and  the  vascular  nsevus,  or  angioma.  Nsvi  are  found  in  all  parts  of 
the  body,  but  occur  most  frequently  on  the  face,  neck,  and  back. 
Their  etiology  is  obscure.  Aside  from  disfigurement  they  are  of  little 
importance  except  that  vascular  nsevi  may  be  injured  and  bleed  pro- 


PEMPHIGUS  NEONATORUM  601 

fusely,  and  moles  sometimes  begin  to  grow  quickly,  and  become 
m.alignant. 

Treatment. — Small  cutaneous  and  subcutaneous  angiomata  m.ay 
disappear  spontaneously.  Larger  ones  are  most  successfully  treated 
with  radium,  or  may  be  removed  by  applications  of  CO2  snow,  but  the 
port-wine  colored  variety  is  very  hard  to  efface.  Electricity  is  some- 
times employed  with  great  success  in  the  removal  of  angiomata. 

Moles  require  no  treatment  unless  they  begin  to  grow  rapidly,  when 
they  should  be  excised  at  once.  Hairy  moles  are  best  treated  with 
CO2  snow  (Figs.  62  and  63). 

GANGRENOUS    DERMATITIS. 

• 

This  disease  is  a  multiple  gangrene  of  the  skin  seen  during  infancy, 
usually  before  the  third  year.  It  follows  variola,  varicella,  vaccinia, 
and  rubeola.  In  some  cases  a  co-existing  tuberculosis,  syphilis,  or 
rickets  has  been  observed. 

Symptoms. — After  one  of  the  exanthemata,  an  ulcer  follows  the 
eruption,  and  a  slough  is  thrown  off.  If  several  ulcers  have  coalesced 
the  tissue  loss  may  be  great.  Occasionally  the  gangrenous  points 
appear  on  normal  areas  of  skin.  The  head,  shoulder,  and  trunk  are 
the  most  common  sites.  If  the  ulcers  are  numerous,  they  may  cause 
marked  constitutional  symptoms.  After  sloughing  a  process  of  repair 
sets  in,  and  a  vacciniform  scar  is  left  at  the  site  of  each  ulcer. 

Treatment. — The  general  condition  of  the  child  should  be  supported. 
Local  treatment  consists  in  dressing  the  ulcers  antiseptically,  and 
applying  deodorants  to  the  sloughing  tissue.  The  outlook  in  the 
majority  of  cases  is  very  grave,  in  spite  of  most  careful  treatment. 

PEMPHIGUS    NEONATORUM. 

Pemphigus  neonatorum  is  the  title  given  to  impetigo  contagiosa 
bullosa  occurring  in  the  newborn.  It  appears  in  infants  both  sporadic- 
ally and  epidemically,  epidemics  being  more  commonly  seen  in  the 
obstetric  wards  of  large  hospitals.  The  disease  is  of  infectious  origin, 
and  probably  due  to  the  staphylococcus  aureus. 

Symptoms. — The  eruption  com.m.only  appears  between  the  fifth  and 
twentieth  days  of  a  child's  life,  and  shows  a  predilection  for  the  abdo- 
men, inguinal  region,  face,  and  hands,  but  the  lesions  may  appear  on 
any  part  of  the  body.  The  eruption  consists  of  vesicles  and  bullae 
situated  on  an  erythematous  base.  They  vary  in  size,  and  contain 
either  serous  or  purulent  fluid  which  spreads  the  infection  when  the 
lesions  burst.  In  mild  cases  there  are  few  constitutional  symptoms; 
when  severe,  the  lesions  are  very  numerous  and  are  accompanied  by 
diarrhea,  anorexia,  fever,  and  exhaustion. 

Diagnosis. — If  there  are  no  other  signs  of  syphilis  present,  the  absence 
of  lesions  on  the  soles  and  palms  will  differentiate  pemphigus  neona- 
torum from  syphilitic  pemphigus. 


602  DISEASES  OF   THE  SKIN 

Treatment. — Absolute  cleanliness  is  essential,  and  when  the  involved 
area  is  large^  warm  baths  should  be  given  twice  daily.  Dusting 
powders  of  starch,  boric  acid,  bismuth  subnitrate,  or  zinc  stearate  may 
be  used.  The  vesicles  may  be  opened,  and  an  ointment  of  2  per 
cent,  ammoniated  mercury  applied.  vSupportive  treatment  is  indi- 
cated in  severe  cases,  as  it  is  the  bottle-fed,  cachetic  baby  that  usually 
succumbs  to  this  disease.  Healthy  babies  generally  recover  in  from 
two  to  three  weeks,  and  in  these  infants  the  disease  never  approaches  a 
severe  degree. 

DERMATITIS   EXFOLIATIVA    NEONATORUM. 

This  is  also  known  as  Ritter's  disease.  It  is  very  rare,  and  is  believed 
to  be  closely  related  to*  pemphigus.  It  occurs  in  infants  between  the 
first  and  fifth  weeks,  most  commonly  in  foundling  asylums.  The 
cause  of  Ritter's  disease  is  unknown.  Its  relation  to  pemphigus  is 
upheld  by  some  authorities,  while  others  consider  it  to  be  merely  an 
exaggeration  of  the  normal  exfoliation  of  the  newborn.  The  majority 
of  cases  have  been  observed  in  boys. 

Symptoms. — In  some  cases  the  disease  begins  with  a  dryness  of  the 
skin,  VN'hile  in  others  there  is  inflammation  of  the  oral  mucous  mem- 
brane. This  is  followed  by  a  diflfuse  redness  all  over  the  body.  As  the 
hyperemia  spreads,  the  area  which  first  became  reddened  begins  to 
desquamate.  The  desquamation  may  be  perfectly  dry,  or  accompanied 
by  the  formation  of  bullae  filled  with  fluid.  After  desquamation,  the 
skin  is  irritable  for  a  few  days,  and  then  returns  to  normal.  There  is 
usually  no  fever,  and  uncomplicated  cases  show  no  systemic 
disturbances. 

Delicate  children  who  have  Ritter's  disease  are  apt  to  develop  com- 
plications, such  as  furunculosis,  gangrene,  gastro-intestinal  disturbance, 
or  pneumonia,  which  usually  brings  about  a  fatal  termination,  but 
healthy  children  quite  frequently  recover.  The  disease  shows  a 
mortality-rate  of  about  50  per  cent. 

Diagnosis. — The  differentiation  between  Ritter's  disease  and  pem- 
phigus is  very  difficult,  since  the  two  diseases  are  related.  Ritter's 
disease  is  differentiated  from  the  general  exfoliation  of  the  skin  caused 
by  syphilis  by  the  absence  of  other  evidences  of  lues. 

Treatment. — Prophylaxis  consists  in  cleanliness,  and  the  avoidance 
of  all  local  irritation.  The  child's  state  of  nutrition  usually  needs 
improvement,  and  the  warmth  of  the  body  should  be  maintained. 
Locally,  an  ointment  containing  1  per  cent,  salicylic  acid  or  phenol 
should  be  employed,  or  the  following: 

I^ — Hydrarg.  ammoniata 5ij 

Petrolati §ij — M. 

MOLLUSCUM   CONTAGIOSUM. 

Molluscum  contagiosum  is  a  form  of  contagious  wart  within  which 
there  occurs  a  peculiar  degeneration.     The  affection  is  much  more 


PARASITIC  SKIN  DISEASES  603 

common  in  children  than  in  adults,  and  epidemics  are  not  uncommonly 
seen  in  institutions.  The  etiology  of  molluscum  contagiosum  is  still 
obscure,  but  the  theory  of  the  parasitic  nature  of  the  disease  has  been 
universally  accepted,  although  no  definite  organism  has  been  isolated. 

Symptoms. — The  eruption  appears  as  small,  firm  nodules,  which  are 
tense  and  shiny,  of  whitish  color,  and  w^axy  appearance.  There  is  a 
central  umbilication  from  which  sebaceous  material  may  be  expressed. 
The  eruption  occurs  principally  upon  the  face,  neck,  and  arms. 

Diagnosis. — Molluscum  contagiosum  does  not  resemble  any  other 
skin  disease.  Warts  of  the  ordinary  type  may  possibly  be  mistaken 
for  it,  but  they  do  not  commonly  appear  on  the  face,  and  have  no 
central  umbilication. 

Treatment. — Multiple  punctures  of  the  nodules  will  usually  cause 
their  disappearance  in  a  few  days.  If  there  be  but  few  lesions,  the 
sebaceous  material  may  be  squeezed  out  of  each  individual  nodule, 
and  a  cure  thus  effected.  If  the  disease  is  widespread  over  the  body, 
applications  of  tincture  of  green  soap  or  5  per  cent,  sulphur  ointment 
are  advisable. 

PARASITIC    SKIN   DISEASES. 

Parasitic  skin  diseases  are  more  common  among  the  children  of  the 
poor,  but  may  be  seen  in  all  classes,  on  account  of  the  close  contact  of 
children  at  school  and  at  play.  Both  animal  and  vegetable  parasites 
infest  the  skin.  Of  the  animal  parasites,  pediculi  and  the  itch  mite 
are  most  frequently  encountered,  while  fungi  which  produce  ringworm 
of  the  scalp  and  favus  are  the  most  common  vegetable  parasites. 

Pediculosis. — Pediculosis  is  that  condition  in  which  the  child  is  the 
host  of  pediculi  or  lice.  In  young  children  the  pediculosis  capitis, 
or  head  louse,  is  most  frequently  found;  occasionally  the  crab  louse,  or 
pediculosis  pubis,  will  be  observed  on  the  eyelids  of  young  children. 
Later  in  childhood  one  finds  the  pediculosis  corporis,  or  body  louse,  and 
the  pediculosis  pubis. 

The  pediculi  found  in  the  scalp,  pubic  hair,  and  body  hair  form 
respectively  three  distinct  varieties  of  lice.  They  are  very  prolific, 
each  female  when  three  weeks  old  laying  about  fifty  eggs.  The  eggs 
of  the  body  louse  are  deposited  in  the  underclothing,  but  the  eggs 
of  the  other  types  are  found  attached  to  the  hairs,  and  are  known  as 
nits. 

Symptoms. — After  attaching  itself  to  the  skin  the  parasite  sucks  the 
blood,  and  causes  intense  irritation  and  itching,  which  result  in  vigor- 
ous scratching  on  the  part  of  the  child.  Many  cases  of  eczema,  especi- 
ally of  the  scalp,  have  their  beginning  as  pediculosis.  In  every  case 
there  is  severe  inflammation  of  the  skin  from  the  irritation  and  scratch- 
ing, and  the  lymphatic  glands  draining  the  affected  area  may  become 
enlarged,  as  is  often  the  case  with  the  enlargement  of  the  postcervical 
glands  seen  in  pediculosis  capitis. 

Diagnosis. — The  diagnosis  is  made  by  identifying  the  pediculi, 
which  may  readily  be  seen  under  a  low  power  glass.     The  nits  are 


604  DISEASES  OF   THE  SKIN 

visible  to  the  naked  eye.  Pediculosis  corporis  is  sometimes  confused 
with  scabies;  but  the  distribution  of  the  lesions  differs,  and  no  burrows 
are  to  be  found  in  pediculosis  corporis. 

Treatment. — Removal  of  the  hair  from  the  affected  regions  is  a  great 
help  in  every  case.  If  this  be  objected  to,  the  hair  must  be  gone  over 
carefully  with  a  fine-tooth  comb.  Kerosene  is  a  good  application,  but 
is  disagreeable,  and  a  solution  of  bichloride  of  mercury,  1  grain  to  the 
ounce  of  water,  is  just  as  effective.  To  this  may  be  added  dilute 
acetic  acid,  which  will  loosen  the  nits,  and  facilitate  their  removal  from 
the  hairs. 

If  the  irritation  is  severe,  a  5  per  cent,  phenol  solution  may  be 
applied  to  the  scalp,  or  a  10  per  cent,  boric  acid  ointment  rubbed  in. 
The  head  should  be  thoroughly  washed  each  morning,  and  the  para- 
siticide reapplied  until  all  pediculi  and  nits  have  been  removed. 

Pediculosis  corporis  may  be  eradicated  by  daily  bathing,  and  a 
change  of  underclothing  after  each  bath.  The  discarded  under- 
garments should  be  soaked  in  a  5  per  cent,  carbolic  solution  before 
they  are  used  again.  An  ointment  containing  5  per  cent." phenol  or 
the  following  prescription  is  often  beneficial: 

I^ — Olei  olivae f  gii.i 

Olei  petrolei f  §vi 

Balsam  Peruv f §j — M. 

Sig. — Apply  to  scalp  on  retiring. 

SCABIES. 

Scabies  is  a  contagious  skin  disease  due  to  the  presence  of  the  itch 
mite,  or  acarus  scabiei,  in  the  skin.  The  female  buries  herself  in  the 
skin,  making  a  burrow  in  which  she  deposits  eggs  and  feces.  This 
produces  on  the  skin  an  eruption  of  vesicles,  pustules,  and  nodules. 
The  itching  is  severe,  and  is  worse  at  night,  so  that  scratch  marks  are 
added  to  the  eruption.  The  burrows  are  elevated,  and  grayish  in 
color;  with  the  aid  of  a  magnifying  glass  the  parasite  may  be  seen  at 
one  end. 

The  distribution  of  the  eruption  is  characteristic,  for  the  mites  seek 
moist,  warm  places  for  burrowing,  therefore  the  lesions  of  scabies  are 
most  abundant  in  the  interdigital  spaces,  the  wrists,  the  flexor  sur- 
faces of  the  forearms,  between  the  toes,  in  the  under  surfaces  of  the 
thighs,  and  on  the  scrotum  and  penis. 

Diagnosis. — The  diagnosis  of  scabies  is  certain  when  the  burrows 
have  once  been  demonstrated  in  the  skin  of  the  child.  The  distribution 
of  the  eruption,  the  history  of  contagion,  and  the  itching,  worse  at 
night,  are  points  which  differentiate  scabies  from  pediculosis  or  eczema. 
An  eczema  frequently  appears  as  a  result  of  scabies,  and  may  tend  to 
mask  the  original  condition. 

Treatment. — The  treatment  of  scabies  consists,  for  the  main  part, 
in  the  destruction  of  the  itch  mite,  but  this  is  difficult  to  accomplish 
without  causing  a  dermatitis  or  eczema  by  the  parasiticide  used.     The 


DERMATITIS  MEDICAMENTOSA 


605 


first  step  should  be  to  remove  the  clothing  and  bedclothes,  and  to 
sterilize  them.  The  child  should  be  given  a  warm  bath,  using  plenty 
of  soap,  followed  by  a  vigorous  rubbing  with  a  rough  towel.  The  skin 
should  then  be  anointed  with  an  ointment  containing  balsam  of  Peru 
and  sulphur,  1  dram  each  to  the  ounce  of  petrolatum.  This  ointment 
should  be  reapplied  for  three  successive  evenings  following  the  first 
application,  but  no  baths  should  be  given  during  this  time,  and  the 
same  underclothing  should  be  worn.  After  the  fourth  application  of 
the  parasiticide,  another  warm  bath  is  given,  and  fresh  underclothing 
put  on. 

If  dermatitis  or  eczema  results  from  the  treatment,  this  should  now 
receive  attention.  If  not  completely  eradicated,  a  second  course  of 
treatment  similar  to  the  first  will  usually  result  in  the  disappearance 
of  all  evidences  of  scabies. 

When  treating  scabies  in  very  young  infants,  a  solution  of  styrax, 
one-half  ounce  to  the  ounce  of  lanolin,  is  just  as  effective  as  the 
sulphur  preparation,  and  is  less  liable  to  cause  dermatitis. 

R — Sulphuris 3ij 

Hydrarg.  ammoniata     . .      .      .  gr.  xx 

Creosote gtt.  xx 

Lard q.  s.  ad.  3iv-<-M. 

Sig. — Apply  locally. 


Fig.  G4. — Bromide  rash. 


DERMATITIS    MEDICAMENTOSA. 

This  includes  all  eruptions  caused  by  the  administration  of  drugs. 
As  a  rule,  the  skin  lesions  appear  after  some  days  or  weeks  of  con- 
tinuous dosage ;  occasionally,  however,  they  may  develop  after  a  very 
small  amount  of  the  medicine  has  been  taken. 

Certain  drugs,  especially  the  bromides,  belladonna,  the  iodides, 
quinin,  salicylic  acid,  mercury,  arsenic,  and  many  coal-tar  derivatives, 
are  apt  to  produce  cutaneous  eruptions.     Some  of  these,  as  the  bro- 


606 


DISEASES  OF   THE  SKIN 


mides,  iodides,  and  belladonna,  usually  produce  a  rash,  others  less 
regularly  do  so.     Some  children,  too,  are  very  susceptible. 

The  rashes  caused  by  the  administration  of  bromides  are  commonly 
pustular,  less  often  furuncular  and  carbuncular.  There  may  occasion- 
ally be  some  superficial  ulceration;  very  rarely  papillomatous  or 
vegetative  lesions  occur.  Bromide  lesions  do  not  leave  any  permanent 
disfigurement,  although  the  rash  may  persist  for  four  or  five  weeks 
after  the  bromides  have  been  discontinued  (Fig.  6i). 


Fig.  65. — Tuberculosis  cutis. 


TUBERCULOSIS    CUTIS. 

The  tubercle  bacillus  may  also  produce  lesions  of  the  skin,  usually 
suppurative  or  ulcerative  in  character.  These  lesions  are  generally 
due  to  the  extension  to  the  skin  of  some  underlying  tuberculous  process. 
The  superficial  skin  is  more  or  less  destroyed,  the  edges  are  red  and 
undermined,  and  the  granulations  thinly  covered  with  pus.  The 
lesions  spread  slowly  and  cause  very  little  pain.  Occasionally  the 
disease  assumes  a  papulopustular  form,  which  is  most  commonly  seen 
on  the  face  and  upper  extremities.  An  ulcerative  papillomatous 
tuberculosis  occasionally  occurs,  and  is,  as  a  rule,  found  on  the  lower 
leg  or  hand  (Fig.  65). 


CHAPTER  XXI. 

DISEASES  OF  THE   EAR. 

Diseases  of  the  ear  are  quite  common  in  children  at  all  ages. 
During  infancy,  otitis  is  usually  primary,  but  in  later  child  life  it 
is  commonly  secondary  to  one  of  the  exanthemata. 

FOREIGN   BODIES    IN    THE   EAR. 

The  presence  of  foreign  bodies  in  the  ear  is  not  usually  attended 
with  severe  symptoms  or  grave  consequences,  but  efforts  at  removal, 
if  not  skilfully  directed,  may  do  much  harm.  Children  are  in  the 
habit  of  putting  things  in  the  ear,  and  for  this  reason  the  variety  of 
articles  which  has  been  removed  from  the  ears  of  children  is  large. 
They  are  divided  into  three  groups:  animate  objects,  such  as  bugs 
and  insects — inanimate  objects  influenced  by  moisture,  such  as  beans, 
onions,  tea  and  wheat — and  inanimate  objects  uninfluenced  by  mois- 
ture, such  as  beads,  pebbles,  and  buttons.  Insects  should  be  killed 
by  filling  the  auditory  canal  with  warm  water  or  whisky  before  an 
attempt  is  made  to  syringe  them  out. 

Objects  in  the  ear  influenced  by  moisture  may  be  reduced  in  size 
by  instilling  pure  alcohol  before  attempting  extraction.  Even  if  the 
object  be  uninfluenced  by  moisture,  instillation  of  alcohol  will  tend 
to  reduce  any  swelling  of  the  auditory  canal  and  facilitate  its  removal. 
Syringing  an  object  out  of  the  ear  is  preferable  to  using  instruments, 
and  should  be  successful  if  the  stream  can  be  directed  back  of  the 
foreign  body.  In  some  cases  turning  the  head  sidew^ise  with  the  ear 
lowermost,  and  striking  the  head  from  below,  may  dislodge  the 
object. 

ACUTE    OTITIS    MEDIA. 

Acute  otitis  media  is  an  inflammation  of  the  middle  ear,  and  may 
be  catarrhal  or  suppurative. 

Etiology. — In  severe  cases  of  scarlet  fever,  diphtheria,  and  to  a  less 
degree  in  measles,  especially  when  the  throat  symptoms  are  severe, 
there  is  a  distinct  tendency  to  inflammation  of  the  middle  ear,  and 
there  is  certainly  a  probability  of  more  or  less  inflammation  of  the 
ear  in  all  infectious  diseases  of  childhood.  In  bathing  infants,  water 
may  gain  entrance  to  the  tympanic  cavity  through  the  upper  segment 
of  the  drumhead,  which  is  not  always  closed  at  birth,  and  this  gives 
rise  to  otitis  media. 

The  mucous  membrane  lining  the  tympanic  cavity  is  embryonic 
in  type  during  infancy,  and  this  also  predisposes  to  inflammation. 


608  DISEASES  OF  THE  EAR 

« 
Cachexia  and  bronchitis  are  two  important  factors  in  the  etiology  of 
otitis  media  in  infancy.  Coughing,  vomiting  and  sneezing  may  force 
matter  through  the  Eustachian  tubes  into  the  middle  ear  and  thus 
give  rise  to  suppuration.  Adenoids  and  diseased  tonsils,  syphilis  and 
tuberculosis,  all  predispose  to  middle-ear  disease  during  childhood. 

It  has  been  stated  that  pathogenic  bacteria  may  be  found  normally 
in  the  tympanic  cavity,  and,  therefore,  any  local  change  in  the  con- 
dition of  the  mucous  membrane,  such  as  congestion  from  any  cause, 
may  result  in  an  otitis  media. 

Otitis  media  is  sometimes  present  in  the  newborn,  and  is  supposed 
to  be  caused  by  the  forcible  entrance  of  amniotic  fluid  into  the  middle 
ear  during  delivery. 

Pathology. — The  pathological  changes  vary  from  the  simple  catarrhal 
inflammation  which  usually  accompanies  catarrh  of  the  rhinopharynx 
or  measles  to  the  phlegmonous  form  with  infiltration  and  purulent 
secretion  seen  after  scarlet  fever,  influenza  or  diphtheria.  The  simple 
catarrhal  form  of  otitis  media  is  characterized  by  swelling  and  cloud- 
ing of  the  mucosa,  and  the  production  of  a  slight  quantity  of  sero-pus. 
There  is  usually  very  slight  pain  and  the  inflammation  subsides  in  the 
course  of  a  few  days  with  no  serious  results  following.  This  form  is 
seen  most  frequently  during  infancy. 

In  older  children  the  suppurative  form  is  most  common.  It  is  caused 
by  the  action  of  a  great  number  of  virulent  bacteria  on  a  devitalized 
mucous  membrane  in  the  tympanic  cavity.  The  membrane  is  first 
hyperemic,  then  it  becomes  infiltrated,  and  there  is  a  purulent  exudate. 
This  inflammatory  process  may  extend  to  the  cellular  tissues  above 
the  tympanum.  The  Eustachian  tube  becomes  blocked  up  and  the 
tympanic  membrane  is  finally  ruptured  by  the  force  of  the  pent-up 
secretion  in  the  tympanic  cavity.  Necrosis  of  the  ossicles  may  result, 
and,  by  extension,  the  inflammation  may  give  rise  to  periostitis, 
pachymeningitis,  thrombosis  of  the  lateral  sinus,  and  cerebral  abscess. 

Bacteriology. — The  organisms  found  most  frequently  in  otitis  media 
are  the  streptococcus,  staphylococcus,  and  pneumococcus.  The  tuber- 
cle bacillus  may  be  present  in  chronic  cases,  and  the  Klebs-Loeffler 
bacillus  has  been  isolated  in  cases  of  otitis  secondary  to  diphtheria. 

Symptoms. — The  symptoms  of  acute  otitis  media  are  very  often 
variable  and  obscure.  In  infants  with  cachexia  as  an  underlying 
cause,  there  may  be  no  subjective  symptoms.  On  inspection,  the 
drumhead  is  slightly  reddened  and  a  small  amount  of  slimy  secretion 
may  be  found  in  the  auditory  canal.  The  nutrition  is  often  dis- 
turbed in  otitis  of  infancy,  and  the  child  nurses  poorly.  It  may  refuse 
to  nurse  except  on  the  side  which  allows  it  to  place  the  affected  ear 
to  the  mother's  breast.  It  is  peevish,  twists  its  head  or  drops  it  to 
one  side,  and  cries  out  continually.  The  pain  is  worse  at  night  and  the 
fever  is  higher  than  during  the  day,  so  that  the  child  is  restless  and 
may  make  sudden  outcries  in  its  sleep. 

Pain  and  temperature  are  the  two  constant  features  of  otitis  in 
children.     The  temperature  range  in  these  cases  is  from  100°  F.  to 


ACUTE  OTITIS  MEDIA  609 

104°  F.  In  some  cases  there  is  anorexia,  nausea,  vomiting,  and  marked 
apathy.  These  symptoms  usually  persist  for  a  week  or  ten  days  when 
a  purulent  secretion  is  found  in  the  canal.  Examination  of  the  ear 
drum  will  usually  reveal  the  site  of  rupture  of  the  tj^mpanic  membrane. 
The  discharge  of  pus  is  followed  by  a  drop  in  temperature  and  rapid 
subsidence  of  all  symptoms.  As  a  rule  there  are  no  complications  in 
this  form  of  otitis  during  infancy. 

In  older  children  the  symptoms  are  more  severe.  The  pain  is 
intense  and  becomes  excruciating  just  before  rupture  of  the  drum- 
head. Evidences  of  meningeal  and  labyrinthine  irritation  are  present 
and  include  nystagmus,  vomiting,  convulsions,  and  unconsciousness. 
Headache  and  delirium  are  also  not  uncommon.  A  child  with  otitis 
will  often  complain  of  noises  heard  in  the  ear.  It  is  very  restless,  cries 
incessantly  and  rubs  or  strikes  the  ear  with  its  hand. 

Otoscopic  examination  reveals  the  ear  drum  markedly  congested 
and  irregular  in  contour.  The  upper  and  posterior  walls  of  the  meatus 
are  swollen.  The  mastoid  is  very  tender  and  there  is  a  swelling  of  the 
tissues  covering  the  bone  and  extending  downward  along  the  whole 
side  of  the  neck  and  forward  to  the  retromaxillary  fossa.  The  inflam- 
mation may  not  go  on  to  suppuration  if  the  symptoms  are  mild,  but 
as  a  rule  there  is  pus  formation  which  causes  first  a  bulging  of  the 
tympanic  membrane,  and  then,  as  the  tympanic  cavity  fills  up  with 
pus,  the  ear  drum  is  ruptured. 

The  temperature  in  otitis  media  purulenta  is  the  most  constant 
sign  and  may  be  the  only  indication  of  a  complication  in  one  of  the 
exanthemata.  It  usually  reaches  102°  F.,  but  the  cdurse  is  irregular 
and  many  cases  range  from  103°  F.  to  105°  F.  until  rupture  of  the 
membrane,  when  the  temperature  falls  and  other  symptoms  subside. 
If  the  drumhead  be  resistant  so  that  rupture  is  delayed,  the  suppura- 
tive process  may  extend  down  the  neck  into  the  throat  and  cause  a 
retropharyngeal  abscess,  or  into  the  middle  fossa  of  the  skull,  or  to 
the  lateral  sinus. 

During  the  course  of  diphtheria,  measles,  scarlet  fever  or  typhoid 
fever,  many  of  the  symptoms  of  an  otitis  media  may  be  easily  over- 
looked or  attributed  to  the  primary  disease,  so  that  a  routine  examina- 
tion of  the  ears  should  be  made  during  the  course  of  all  exanthemata. 

Diagnosis. — An  early  diagnosis  of  acute  purulent  otitis  media,  while 
it  is  apt  to  be  very  difficult  if  the  otitis  is  secondary,  is  important,  as 
the  child's  future  hearing  may  depend  upon  the  time  that  it  is  made. 
A  diagnosis  after  ruptiue  of  the  drumhead  and  perhaps  threatened 
mastoiditis  or  necrosis  of  the  ossicles,  is,  of  course,  a  simple  procedure. 
An  otoscopic  examination  is  always  necessary,  since  many  of  the 
symptoms  of  a  secondary  otitis  may  be  attributed  to  meningeal  irri- 
tation from  the  primary  disease. 

Some  cases  of  otitis  media  in  infants,  when  the  symptoms  are  mild, 
may  even  fail  to  show  any  positive  signs  of  otitis  on  otoscopic  examina- 
tion. Fever  may  be  the  only  manifestation,  and  in  the  absence  of  any 
signs  in  the  ear,  the  diagnosis  must  be  made  by  exclusion  of  any 
39 


610  DISEASES  OF  THE  EAR 

cause  for  fever  in  the  throat,  lungs  or  gastro-intestmal  tract.  Older 
children  will  complain  of  pain  or  tenderness  about  the  ear,  or  of  deaf- 
ness and  noises  heard  in  the  ear. 

Furunculosis  or  foreign  bodies  in  the  auditory  canal  may  produce 
symptoms  which  simulate  otitis  media,  but  their  presence  is  quickly 
revealed  by  otoscopic  examination.  A  case  of  primary  acute  suppura- 
tive otitis  media  presents  no  difficulty  in  diagnosis  in  older  children, 
and,  if  its  frequency  in  infants  during  cold  weather  be  borne  in  mind, 
it  should  not  be  overlooked  in  infancy. 

Prognosis. — The  prognosis  in  a  catarrhal  otitis  media  is  uniformly 
good.  The  outlook  in  an  acute  purulent  otitis  media  depends  upon 
the  early  diagnosis,  and  presence  or  absence  of  complications.  The 
most  unfavorable  cases  are  those  following  scarlet  fever.  The  mortality 
rate  of  middle-ear  disease  in  children  is  below  1  per  cent. 

Complications  and  Sequelae. — Mastoiditis  is  the  most  frequent  com- 
plication of  purulent  otitis  media. 

Meniiigitis. — Meningitis  is  more  often  a  complication  of  chronic 
otitis  media  but  may  follow  an  acute  attack.  There  are  two  varieties : 
the  serous  and  purulent.  It  results  from  infection  through  the  roof 
of  the  tympanum  m  most  cases,  but  may  be  secondary  to  thrombosis 
of  the  lateral  sinus,  or  rupture  of  a  cerebral  abscess.  The  symptoms 
come  on  suddenly  and  there  is  headache,  contraction  of  the  pupil  and 
nystagmus  toward  the  affected  ear.  The  pulse  is  rapid,  the  respirations 
increased  and  projectile  vomiting  may  occur.  The  patient  is  ataxic, 
the  muscles  of  the  face  and  extremities  are  drawn  or  contracted,  and 
the  head  is  retracted  by  the  contraction  of  the  head  muscles. 

As  the  disease  progresses,  delirium  is  followed  by  somnolence  or 
apathy  and  loss  of  memory.  The  distinction  between  serous  and  puru- 
lent meningitis  is  made  by  examination  of  the  spinal  fluid,  which  show  s 
no  pus  or  bacteria  in  the  former,  and  an  abundance  in  the  latter.  The 
prognosis  of  the  serous  meningitis  is  good,  while  the  purulent  form  is 
almost  invariably  fatal. 

Brain  Abscess. — Middle-ear  disease  is  the  most  frequent  cause  of 
abscess  of  the  brain,  but  it  usually  follows  chronic  otitis  media.  The 
infection  gains  access  through  the  bone,  veins  or  dura  mater,  and 
in  most  cases  the  abscess  is  in  the  temporosphenoidal  lobe.  The 
symiptoms  are  pain,  vomiting,  subnormal  temperature,  slow  pulse, 
constipation  and  retention  of  urine.  The  child  is  usually  apathetic. 
Localizing  symptoms  depend  upon  the  site  of  the  abscess.  The  prog- 
nosis of  brain  abscess  is,  as  a  rule,  bad,  but  early  operation  may  often 
result  in  recovery. 

Septic  Sinvs  Thrombosis. — This  complication  is  caused  by  the  occlu- 
sion of  the  lateral  sinus  by  an  infected  clot,  due  to  a  loss  of  integrity 
of  the  intima  of  the  sinus.  It  usually  follows  mastoiditis  or  labyrin- 
thine inflammation.  The  symptoms  are  severe.  There  is  a  widely 
fluctuating  temperature  with  chills,  violent  headache  and  a  marked 
tenderness  over  the  posterior  triangle  of  the  neck  and  jugular  vein. 
Vomiting  is  a  frequent  occurrence  and  convulsions  are  not  unusual. 


ACUTE  OTITIS  MEDIA  611 

The  child  grows  apathetic  and  stuporous  and  coma  precedes  death 
which  usually  occurs  in  twenty-four  to  forty-eight  hours. 

Facial  Paralysis. — Facial  paralysis  is  more  frequently  a  complica- 
tion of  chronic  otitis  media,  and  is  due  to  an  extension  of  the  inflam- 
matory process  from  the  bone  to  the  seventh  nerve  where  it  passes 
through  the  canal. 

Labyrinthitis. — Labyrinthitis  may  be  either  suppurative  or  non- 
suppurative. It  is  rarely  seen  as  a  complication  of  otitis  media  where 
treatment  has  been  prompt  and  thorough. 

Treatment  of  Otitis  Media. — Because  of  the  dire  results  which  some- 
times follow  an  acute  attack  of  otitis  media  in  children,  prophylaxis 
is  an  extremely  important  part  of  the  treatment.  Tonsils  and  adenoids, 
as  common  predisposing  factors,  should  be  removed.  During  the 
course  of  the  exanthemata  and  other  acute  febrile  diseases,  the  naso- 
pharynx should  receive  special  attention  and  careful  cleansing.  Warm 
salt  water  or  liquid  albolene  should  be  instilled  into  the  nose  twice 
daily  with  a  dropper;  the  use  of  nasal  douches  or  syringes  should  be 
avoided.  The  ears  should  be  syringed  daily  with  warm  boric  acid 
solution. 

A  mild  attack  of  acute  catarrhal  otitis  media  will  often  subside  if 
the  ear  be  carefully  irrigated  with  saline  solution  at  a  temperature  of 
110°  F.  The  child  should  be  put  to  bed,  the  diet  restricted,  and  a 
thorough  purge  administered.  Local  blood-letting  may  abort  sup- 
puration in  a  child,  but  should  never  be  practised  in  an  infant.  The 
artificial  leech  is  usually  employed. 

Hot  applications  are  soothing  for  the  pain,  and  dry  heat  is  prefer- 
able to  wet  heat.  The  best  results  are  obtained  from  the  use  of  rays 
of  a  high -candle-power  electric  light  (200  to  300  c.  p.),  but  a  hot- 
water  bag  or  a  bag  of  salt  heated  may  serve  the  purpose.  It  may  be 
necessary  to  instil  a  4  per  cent,  cocaine  or  5  per  cent,  phenol  solution 
into  the  ear  for  the  pain,  but  the  mother  should  be  warned  against 
dropping  oil  of  any  kind  into  the  auditory  canal. 

Frequent  otoscopic  examinations  should  be  made  if  a  child  has 
acute  otitis,  and  as  soon  as  suppuration  is  indicated  the  drumhead 
should  be  incised.  Myringotomy  is  such  an  important  measure  in 
treatment  that  it  should  be  done  if  there  is  the  slightest  suspicion  of 
pus,  for  in  many  cases  where  the  drumhead  is  incised  and  no  pus 
obtained  there  has  been  instant  amelioration  of  symptoms  without 
pus  formation.  The  incision  should  be  long  and  curved  to  allow  the 
discharge  to  flow  through  it.  The  after-treatment  may  be  either  wet 
or  dry. 

The  dry  method  consists  in  wiping  out  the  exudate  from  the 
external  auditory  canal  and  the  use  of  silver  nitrate,  3  to  5  grains  to 
the  ounce,  as  an  application  in  the  tympanic  cavity.  The  ear  may 
then  be  dusted  with  equal  parts  of  boric  acid  and  zinc  oxide.  The  wet 
method  is  carried  out  by  repeated  syringing  of  the  ear  with  hot  salt 
solution  or  copper  or  zinc  sulphate,  gr.  viii  to  the  ounce  of  water. 

If  the  discharge  lessens  and  the  temperature  persists,  the  drainage 


612  DISEASES  OF  THE  EAR 

is  imperfect  and  a  secondary  incision  may  be  necessary.  If  the  dis- 
charge persists,  a  few  drops  of  2  per  cent,  silver  nitrate  should  be 
dropped  into  the  tympanic  cavity,  or  the  tympanic  membrane  may  be 
cauterized  with  trichloracetic  acid.  A  fetid  discharge  may  be  alle- 
viated by  the  use  of  hydrogen  peroxide  or  compound  tinctm-e  of  ben- 
zoin in  a  syringe.  An  aurist  should  be  consulted  if  the  discharge  does 
not  cease  within  a  month.  The  presence  of  adenoids  and  other  con- 
ditions in  the  nasopharynx  also  has  a  tendency  to  prolong  an  attack 
of  otitis,  and  these  conditions  should  be  corrected  as  soon  as  possible. 

The  use  of  vaccines  has  been  the  subject  of  much  discussion  recently, 
and  my  experience  with  them  has  been  very  satisfactory.  Autogenous 
vaccines  are  made  by  suspending  dead  bacteria  in  normal  salt  solu- 
tion after  a  culture  has  been  obtained  from  the  pus.  In  this  way  the 
specific  organism  is  isolated  and  used  after  subjecting  it  to  a  tem- 
perature of  60°  C.  for  forty-five  minutes.  Because  of  the  reaction 
it  produces,  vaccine  therapy  is  contra-indicated  in  cases  where  there  is 
a  debilitated  condition  of  the  patient,  or  if  the  child  be  in  a  state  of 
profound  sepsis. 

Subacute  and  chronic  cases  are  benefited  most  by  the  administra- 
tion of  vaccines,  for  the  child  is,  as  a  rule,  in  better  physical  condition 
than  during  acute  attacks.  Cases  which  respond  to  vaccine  treatment 
undergo  rapid  recovery  and  complications  of  otitis  are  rarely  seen. 
A  marked  improvement  is  often  observed  when  vaccines  are  given 
following  operation  for  any  of  the  various  complications  of  otitis.  It 
is  usually  administered  a  week  or  so  after  operation. 

If  vaccine  therapy  is  decided  upon  in  a  case  of  otitis,  injections 
should  be  given  in  increasing  doses  every  three  or  four  days,  but  as 
soon  as  reaction  symptoms,  such  as  a  feeling  of  exhaustion,  etc.,  are 
noticed,  the  injections  should  be  discontinued  for  a  week  or  so  until 
the  vital  forces  are  reestablished. 

Stock  vaccines,  which  may  be  had  from  the  biological  departments 
of  the  large  drug  firms,  do  not  give  as  uniformly  good  results  as  the 
autogenous  vaccines,  because  they  do  not  contain  the  same  strains 
of  organism  which  the  patient  must  react  against.  The  antibodies 
which  are  formed  following  their  injection  are  therefore  not  exactly 
suited  to  counteract  the  specific  bacteria  and  endotoxin  present. 

In  many  cases  they  have  the  objectionable  feature  of  devitalizing 
the  patient  with  no  beneficial  results  in  return.  The  leukocyte  extract 
of  Hiss  may  be  given  with  safety  in  those  cases  of  debility  and  pro- 
found sepsis  where  the  use  of  vaccines  is  contraindicated.  It  contains 
the  elements  of  the  leukocyte  necessary  to  combat  the  bacteria  and 
endotoxin,  and  its  administration  in  no  way  exerts  any  influence  on 
the  vital  forces. 

CHRONIC    SUPPURATIVE    OTITIS   MEDIA. 

Inflammation  of  the  middle  ear  which  has  become  chronic  is  seen 
quite  frequently  during  childhood.     It  is  usually  characterized  by  a 


CHRONIC  SUPPURATIVE  OTITIS  MEDIA  613 

fetid  discharge  and  an  absence  of  subjective  symptoms  except  during 
acute  exacerbations,  which  are  sometimes  quite  frequent. 

Etiology. — Chronic  suppurative  otitis  media  usually  follows  scarlet 
fever,  measles  or  influenza,  and  is  also  frequently  seen  after  diphtheria 
and  typhoid  fever.  Occasionally  a  case  wdll  develop  in  certain  cachec- 
tic conditions  without  previous  acute  phenomena,  but,  as  a  rule,  there 
is  a  history  of  an  acute  purulent  otitis  media  with  spontaneous  rupture 
of  the  drumhead. 

On  otoscopic  examination,  there  is  generally  found  a  state  of  imper- 
fect drainage  caused  by  the  location  of  the  perforation  of  the  drum- 
head or  the  size  of  the  aperture.  Catarrhal  conditions  in  the  naso- 
pharynx and  the  presence  of  adenoids  are  also  predisposing  factors. 
It  usually  develops  in  weakly,  anemic  or  tubercular  children,  and 
tuberculous  otitis  is  chronic  from  the  onset.  Chronic  otitis  involves 
the  tympanic  membrane,  external  meatus,  bony  walls  of  the  middle 
ear,  and  sometimes  the  labyrinth. 

Symptoms. — Persistent  discharge  of  pus  is  perhaps  the  most  constant 
symptom.  In  some  cases  it  is  very  slight,  but  can  usually  be  found  on 
otoscopic  examination.  In  neglected  cases  it  becomes  fetid  and  may 
also  be  blood  streaked  due  to  ulceration,  in  other  cases  the  discharge 
is  more  like  mucus  than  pus. 

There  may  be  headache  or  fulness  in  the  head,  and  often  the  child 
may  complain  of  noises  in  the  ear.  Pain  is  usually  due  to  ulceration 
or  pus  retention.  Acute  exacerbations,  in  which  there  is  pronounced 
pain,  mastoid  tenderness  and  elevation  of  temperature,  are  of  frequent 
occurrence. 

Prognosis. — The  future  hearing  of  the  child,  with  a  chronic  purulent 
otitis  media,  depends  upon  the  site  of  the  perforation  and  the  extent 
of  involvement.  If  there  is  a  central  perforation,  the  hearing  may  be 
but  slightly  affected,  but  if  there  is  marginal  perforation  wdth  bone 
necrosis,  there  may  be  serious  impairment  of  hearing. 

Treatment. — The  treatment  of  chronic  otitis  media  in  children  should 
be  conservative.  If  drainage  is  poor  because  of  a  small  perforation 
in  the  tympanic  membrane,  an  incision  should  be  made  and  the 
opening  enlarged.  The  ear  should  be  syringed  with  bichloride  solution, 
1  to  10,000,  or  hydrogen  peroxide,  saturated  solution  of  boric  acid,  or 
normal  salt  solution,  if  the  wet  method  is  to  be  followed. 

The  dry  method  consists  in  wiping  out  the  secretion,  the  instillation 
of  an  astringent,  and  the  application  of  a  powder  which  is  blow^n  into 
the  ear.  Silver  nitrate  3  to  10  per  cent.,  alcohol  50  per  cent.,  and  argy- 
rol  are  largely  used  in  the  middle  ear,  and  in  some  cases  the  cautery 
may  be  necessary  for  polypi  and  granulations.  Boric  acid,  aristol 
and  iodoform  are  used  as  dusting  powders,  but  they  must  be  finely 
pulverized,  and  care  should  be  taken  that  one  does  not  put  enough 
into  the  canal  to  block  drainage. 

If  there  is  bone  necrosis  or  a  large  number  of  granulations,  operation 
is  necessary  to  effect  a  cure  and  prevent  intracranial  complications  or 
mastoiditis.  If  the  child  has  adenoids,  they  should  be  removed  and 
other  nasopharyngeal  defects  remedied. 


614  DISEASES  OF  THE  EAR 

Autogenous  vaccines  are  especially  to  be  recommended  in  chronic 
suppurative  otitis  media,  as  very  many  excellent  results  have  followed 
their  administration.  In  addition  to  these  measures  for  treatment 
of  chronic  middle-ear  disease,  attention  should  always  be  directed  to 
the  general  health  of  the  child.  Frequently  the  patient  is  found  to 
be  in  poor  physical  condition — anemic,  rheumatic  or  syphilitic,  and 
proper  treatment  of  these  conditions  will  aid  materially  in  the  subsi- 
dence of  the  ear  trouble. 

ACUTE   MASTOIDITIS. 

Acute  infection  of  the  mastoid  process  in  children  is  practically 
always  secondary  to  a  suppurative  otitis  media.  The  occurrence  of 
primary  mastoiditis  as  a  result  of  cold,  or  trauma,  or  furunculosis  of 
the  external  auditory  canal  posteriorly,  is  so  rare  as  to  be  disregarded 
in  the  discussion  of  mastoiditis  during  childhood. 

In  children,  probably  all  suppurative  middle-ear  infections  also 
involve  the  mastoid  cells,  and  it  is  difficult  to  separate  suppuration 
of  the  middle  ear  from  that  of  the  mastoid.  If,  however,  a  case  of 
otitis  media  presents  no  symptoms  of  mastoiditis,  it  is  regarded  as  a 
simple  case  of  otitis  media. 

Etiology. — The  ease  with  which  pus  may  enter  the  mastoid  antrum 
causes  mastoiditis  to  be  a  frequent  complication  of  acute  purulent 
otitis  media  in  children.  The  external  bony  wall  is  thinner  than  in 
adult  life,  the  petrosquamous  suture,  which  is  persistent  in  some 
cases,  passes  through  a  foramen  on  the  inside  of  the  skull  and  appears 
externally  behind  the  glenoid  fossa  and  tympanic  ring,  and  pus  may 
also  find  its  way  externally  more  readily  through  the  open  fissura 
mastoidea  squamosa. 

In  addition  to  this,  the  Eustachian  tube  is  short  and  has  a  wide 
calibre,  which  invites  infection  through  this  source.  Involvement  of 
the  mastoid  is  much  more  apt  to  occur  where  there  is  not  sufficient 
drainage  or  when  incision  of  the  drumhead  has  been  too  long  delayed 
in  an  attack  of  purulent  otitis  media.  As  a  general  rule,  streptococcal 
infection  is  most  liable  to  give  rise  to  mastoiditis.  Mastoiditis  has 
been  observed  as  early  as  the  second  month,  but  most  cases  are  seen 
after  the  second  year. 

Symptoms. — The  symptoms  of  mastoiditis  are  both  local  and 
general.  Those  referable  to  the  mastoid  are  due  to  pressure  from 
retention  of  secretion  within  the  cells.  Pain  is  severe  only  when  the 
cortex  is  thin,  with  more  or  less  necrosis  due  to  otitis  and  periostitis. 
Redness,  tenderness  on  pressure  and  swelling  over  the  mastoid  process 
are  present  in  almost  every  case.  Otorrhea  is  usually  increased  and, 
in  the  absence  of  other  signs  of  mastoiditis,  a  profuse  discharge  is 
indicative  of  mastoid  involvement. 

Otoscopic  examination  reveals  a  bulging  or  drooping  of  the  postero- 
superior  wall  of  the  osseous  canal.  There  is  usually  a  small  central 
perforation  in  the  drumhead  and,  in  some  cases,  granulations  may 


ACUTE  MASTOIDITIS  615 

be  observed  protruding  from  this  aperature  and  obstructing  the 
drainage.  Of  the  general  symptoms  of  mastoiditis,  elevation  of  tem- 
perature is  the  most  constant.  It  ranges  from  99.5°  to  105°  F.  The 
pulse  and  respiratory  rates  are  increased  correspondingly  with  the 
elevation  of  temperature.  The  child  is  restless  at  night  and  may  cry 
out  while  asleep.  During  the  day  it  is  cross  and  irritable.  Occasion- 
ally there  is  vertigo,  vomiting  and  a  convulsion  at  the  onset  of  the 
disease. 

Diagnosis. — ^An  early  diagnosis  of  acute  mastoiditis  in  children  not 
only  prevents  the  occurrence  of  complications,  but  may  save  the  life 
of  a  child,  for  delay  in  operation  always  subjects  the  patient  to  certain 
dangers.  The  diagnosis  is  made  chiefly  on  the  clinical  symptoms, 
physical  signs,  and  the  findings  on  otoscopic  examination. 

Symptoms,  while  important,  are  not  alike  in  all  cases,  and  for  this 
reason  careful  examination  is  sometimes  necessary  to  detect  mastoid 
inflammation.  A  continuous  discharge  from  the  middle  ear  for  over 
four  weeks,  with  fever  and  impaired  hearing,  strongly  suggests  an 
abscess  of  the  mastoid.  One  of  the  most  important  diagnostic  signs 
is  the  drooping  of  the  posterosuperior  wall  of  the  osseous  canal.  The 
a:-ray  and  transillumination  are  sometimes  used  as  an  aid  to  diagnosis. 

Acute  mastoiditis  must  be  differentiated  from  furunculosis  of  the 
external  auditory  canal  and  scalp,  from  erysipelas  of  the  auricular 
region  and  from  lymphangitis  of  the  scalp.  Furunculosis  of  the 
external  auditory  canal  may  give  rise  to  many  of  the  local  signs  of 
mastoiditis,  including  pain,  swelling,  tenderness  and  edema  over  the 
mastoid.  An  otoscopic  examination  quickly  reveals  the  site  of  the 
furuncle,  and  shows  a  normal  tympanic  membrane  and  osseous  canal. 
Hearing  is  affected  in  furunculosis  only  when  there  is  mechanical 
obstruction  by  the  furuncle.     The  temperature  is  rarely  elevated. 

Erysipelas,  involving  the  region  of  the  auricle,  may  be  accompanied 
by  symptoms  suggesting  mastoiditis,  but  careful  inspection  will 
usually  reveal  the  nature  of  this  disease,  and  otoscopic  examination 
shows  a  normal  tympanum  and  osseous  canal.  In  children  with 
pediculosis  capitis,  a  lymphangitis  may  occur  which  will  involve  the 
mastoid  lymph  glands,  and  in  some  cases  simulate  mastoiditis. 

The  differentiation  between  this  affection  and  mastoiditis  is  based 
upon  the  absence  of  any  ear  condition  on  otoscopic  examination,  and 
the  finding  of  the  pediculi  and  the  bilateral  involvement.  An  impor- 
tant differential  feature  in  all  of  these  conditions  is  the  absence  of 
any  previous  history  of  ear  disease  (except  rarely  as  a  coincidence). 

Complications. — The  complications  of  acute  mastoiditis  are  Bezold's 
mastoiditis,  caries  and  necrosis  of  bone  extending  in  any  direction, 
facial  paralysis  and  brain  abscess. 

Treatment. — The  most  important  prophylactic  measure  against 
mastoiditis  is  early  incision  of  the  drumhead  in  acute  purulent  otitis 
media.  In  otitis  following  influenza,  typhoid  fever  or  pneumonia, 
the  drumhead  should  be  incised  immediately,  not  waiting  for  bulging. 
When  a  case  of  acute  mastoiditis  is  seen  before  spontaneous  perfora- 


616  DISEASES  OF  THE  EAR 

tion  of  the  tympanic  membrane  has  taken  place,  the  drumhead  should 
be  freely  incised  at  the  point  of  greatest  bulging.  This  relieves  press- 
ure' and  thus  retards  necrosis. 

The  child  with  mastoiditis  should  be  put  to  bed  and  be  given  a 
course  of  calomel  and  a  dose  of  aconite.  If  the  case  is  seen  at  the 
onset,  an  ice-bag  may  be  placed  over  the  mastoid  for  twelve  to 
twenty-four  hours,  but  once  removed,  should  not  be  reapplied.  Dry 
heat  obtained  by  the  use  of  the  hot-water  bag  is  often  preferable  for 
the  relief  of  pain,  and  in  some  cases  an  opiate  must  be  given.  Leech- 
ing is  of  great  value,  but  should  not  be  used  in  infants  and  is  difficult 
to  perform  in  children. 

In  every  case  it  is  most  desirable  to  obtain  a  reaction  to  inflam- 
mation, and  this  may  be  promoted  sometimes  by  hot  irrigations,  using 
a  1  to  5000  bichloride  solution.  Bier's  hyperemia  has  been  resorted 
to  with  this  object  in  view,  but  authorities  disagree  as  to  its  efficiency, 
and  some  writers  claim  that  the  disease  is  found  more  widespread 
after  its  use.  The  leukodescent  light  may  be  mentioned  as  another 
means  of  securing  a  reaction  to  inflammation,  but  its  use  is  by  no 
means  universal. 

The  treatment  outlined  so  far  should  always  be  carried  out  in  an 
endeavor  to  abort  a  threatened  mastoiditis,  but  once  it  becomes 
apparent  that  the  acute  symptoms  are  not  modified  or  the  infection 
eradicated,  operation  should  be  advised  without  further  delay. 

If  performed  early,  a  mastoid  operation  is  not  formidable  and  the 
results  are  good,  but  a  delay  of  a  few  days  or  a  week  m^y  make  a 
radical  operation  necessary  because  of  the  extent  of  involvement. 
In  advanced  tuberculosis,  general  debility  or  bilateral  involvement 
in  bottle-fed  babies,  however,  operation  should  be  attempted  only 
if  life  is  endangered  by  the  virulence  of  the  infection. 


CHAPTER  XXII. 
THE  SPECIFIC  INFECTIOUS  DISEASES. 

TYPHOID   FEVER. 

Typhoid  fever  is  an  acute  general  infection  caused  by  Eberth's 
bacillus,  the  bacillus  typhosus.  It  occurs  during  intra-uterine  life, 
may  exist  in  the  newborn,  is  comparatively  rare  in  infancy,  and  more, 
common  in  childhood.  It  is  generally  contracted  by  drinking  water 
which  contains  typhoid  bacilli,  by  the  use  of  infected  ice,  by  drinking 
milk  which  has  been  diluted  with  contaminated  water,  by  using  dishes, 
cans,  or  other  utensils  which  have  been  washed  with  such  water,  and 
by  eating  uncooked  vegetables,  such  as  lettuce,  celery,  and  water 
cress,  also  oysters.  In  an  infected  locality  the  only  safety  lies  in 
boiling  for  five  minutes  all  water  used  for  drinking  and  other  house- 
hold purposes.  With  infants  and  children,  the  water  used  in  the  daily 
bath  may  be  a  source  of  mfection  owing  to  their  habit  of  splashing 
it  about  and  putting  their  wet  fingers  in  their  mouths. 

Etiology. — Typhoid  bacilli  are  present  in  the  feces  and  urine  of  all 
typhoid  fever  patients,  and  the  prevalence  of  typhoid  fever  in  any 
locality  points  unmistakably  to  some  imperfection  in  the  disposal 
of  sewage  in  that  district.  It  may  be  carried  by  flies  or  other  insects, 
or  by  dust  containing  dried  human  excreta. 

While  the  disease  is  not  contagious,  and  cannot  be  spread  by  per- 
sonal contact,  still  it  is  true  that  a  child  ill  with  typhoid  fever  should 
be  regarded  as  a  source  of  infection  to  all  those  with  whom  he  comes  in 
contact,  and  all  bed  linen,  articles  of  clothing,  dishes,  etc.,  may  be 
soiled  by  the  fecal  or  urinary  discharges  or  by  the  sputum.  These 
should  be  soaked  in  a  1  to  20  carbolic  solution  and  boiled.  The  hands 
of  all  attendants  should  be  dipped  in  a  creolin  solution  and  washed 
often,  especially  before  eating. 

The  disease  is  more  common  in  temperate  climates,  and  m  the 
autumn  months.  During  infancy  both  sexes  are  equally  affected; 
in  childhood  boys  are  more  exposed,  consequently  more  cases  occur 
among  them  than  in  girls. 

The  typhoid  bacilli  are  found  especially  in  Peyer's  patches,  the 
mesenteric  glands,  and  the  solitary  follicles  of  the  mtestines,  also  in 
the  liver,  spleen,  bile,  bone-marrow,  and  blood,  as  well  as  in  the  rose- 
colored  rash.  In  the  first  few  days  of  the  disease  they  can  be  demon- 
strated in  the  stools  by  cultural  methods.  They  may  occasionally 
be  found  in  the  exudate  of  pleurisy  or  meningitis  occm-ring  during 
typhoid.  They  often  remain  virulent  in  water  and  milk  for  a  period 
varying  from  a  few  days  to  three  months — an  important  fact,  con- 


618  THE  SPECIFIC  INFECTIOUS  DISEASES 

sidering  that  milk  and  water  form  almost  the  exclusive  diet  of  the 
infant.  They  may  also  remain  virulent  in  the  ground  for  long  periods 
of  time,  and  may  not  be  killed  by  freezing  temperatures.  The  bacilli 
are  not  always  destroyed  by  the  dilute  acid  condition  of  the  gastric 
secretions,  and  may  pass  in  a  virulent  state  into  the  intestinal  canal 
where  they  infect  the  system  at  large,  and  multiply  in  the  lymphatic 
tissues. 

Pathological  Anatomy. — In  intra-uterine  typhoid  the  infection  is 
mainly  one  of  the  blood,  and  the  typical  intestinal  and  mesenteric 
lesions  are  absent,  while  in  infants  and  children  the  intestinal  lesions 
are  usually  not  as  marked  as  in  adults.  Peyer's  patches  and  the 
solitary  follicles  are  enlarged,  but  ulceration  is  uncommon,  and,  if. 
present,  is  usually  not  deep,  hence  perforation  seldom  occurs.  In 
typhoid  fever  the  length  of  the  ulcer  corresponds  wdth  the  long  axis 
of  the  intestine,  whereas  in  tuberculous  ulceration  of  the  bowel  the 
greatest  length  of  the  ulcer  is  transverse  in  direction.  Ulceration, 
if  present,  is  more  often  found  in  the  lower  portion  of  the  ileum;  next 
in  frequency  in  the  upper  colon,  which  is  also  the  most  common  seat 
of  perforation.  The  older  the  child  the  more  closely  do  the  intestinal 
lesions  resemble  those  in  the  adult.  The  mesenteric  glands  are  espe- 
cially apt  to  be  involved  in  the  vicinity  of  the  ileocecal  valve. 

Peyer's  patches  and  the  solitary  and  mesenteric  glands  may  show 
only  moderate  inflammation  and  swelling;  but,  as  these  conditions 
are  often  found  in  intestinal  diseases  in  infants  and  children,  one  can 
not  assume  that  the  case  is,  therefore,  one  of  typhoid.  The  disease 
is  often  seen  in  children  after  five  years  of  age,  and  but  8  per  cent, 
of  the  cases  under  five  years,  while  42  per  cent,  are  between  five  and 
eleven  years,  and  50  per  cent,  between  ten  and  fifteen  years.  The 
period  of  incubation  is  from  nine  to  twenty-one  days. 

Typhoid  Fever  in  the  Fetus. — Symptoms. — If  the  mother  has 
typhoid  fever  the  fetus  is  often  infected  with  the  disease,  although 
the  mother  may  have  typhoid,  and  the  fetus  escape.  Miscarriage 
occurs  in  more  than  one-half  the  cases  of  pregnant  women  who  have 
typhoid,  and  the  fetus  is  usually  born  dead,  the  death  of  the  fetus 
being  commonly  the  cause  of  the  miscarriage,  although  the  high 
temperatm-e  or  the  accumulation  of  toxins  in  the  maternal  blood  may 
also  cause  the  premature  expulsion  of  the  fetus.  If  the  fetus  is  born 
alive  it  usually  lives  only  a  few  days,  quickly  succumbing  either  as 
the  result  of  the  intra-uterine  typhoid  infection  or  because  of  its. 
undeveloped,  frail,  and  delicate  physical  condition.  Occasionally  a 
child,  if  born  near  the  end  of  the  pregnancy,  may  outlive  the  attack 
of  typhoid. 

The  typhoid  bacilli  may  pass  from  the  mother  through  the  placenta 
into  the  fetus,  although  it  is  questionable  whether  they  ever  pass 
through  a  healthy  placenta. 

The  infection  occurs  through  the  blood,  the  bacilli  entering  the 
fetus  through  the  umbilical  vein,  and  the  system  at  large  being  sub- 
sequently infected.     The  .disease  is   practically  from   the  beginning 


TYPHOID  FEVER  619 

a  septicemia,  which  explains  the  great  mortahty  in  this  form  of 
the  disease.  The  typical  intestinal  lesions  are  not  found;  indeed, 
in  the  majority  of  cases,  no  intestinal  lesions  are  present,  and  when 
found  they  are  but  slight.  This  is  undoubtedly  due  to  the  absence 
of  function  of  the  bowel  before  birth,  and  to  the  fact  that  no  bacilli 
enter  the  intestinal  tract  from  the  mouth.  The  spleen  may  ^  be 
enlarged,  the  kidneys  may  show  slight  changes,  and  the  liver  may 
present  the  usual  changes  of  typhoid;  occasionally,  slight  lesions 
are  found  in  the  intestinal  mucosa.  The  condition  is,  however,  a 
blood  infection,  the  typhoid  bacilli  being  found  in  the  spleen,  liver, 
kidneys,  and  heart's  blood.  The  Widal  reaction  may  be  obtained 
from  the  blood  of  the  fetus.  In  these  cases  the  agglutinating  factor 
may  have  passed  from  the  mother  to  the  fetus. 

Typhoid  Fever  in  the  Infant. — The  disease  is  less  common  in  the 
first  two  and  a  half  years  of  life  than  in  older  children,  largely  because 
the  infant  is  fed  either  on  breast  milk  or  on  certified  or  pasteurized 
milk.  It  is  undoubtedly  true  that  many  cases  of  the  disease  are  over- 
looked in  infants,  the  possibility  of  typhoid  not  being  considered. 
In  the  older  child  or  adult  a  continued  fever  invariably  suggests  the 
possibility  of  tvphoid,  and  a  Widal  test  is  made.  Owing  to  the  belief 
that  infantile  typhoid  is  rare,  this  test  has  not  commonly  been  applied 
to  infants;  and,  while  the  disease  is  less  common  than  in  later  child 
life,  still  those  who  apply  this  modern  means  of  diagnosis  will  not 
infrequently  meet  with  cases  in  infancy. 

The  disease  runs  a  shorter  course  in  infants.  Prodromata  are  not 
apt  to  be  marked.  Drowsiness,  disturbed  sleep,  loss  of  appetite  and 
indigestion  are  among  the  most  common  symptoms.  The  onset  may 
be  sudden,  with  vomiting  and  fever.  The  duration  of  each  stage  is 
usually  shorter  in  the  infant  than  in  the  child. 

The  mortality  in  infantile  typhoid  is  not  easy  to  determine.  In 
many  of  the  reported  cases,  proven  to  be  typhoid  by  a  Widal,  the 
disease  was  severe  and  the  mortality  high.  If,  however,  many  cases 
of  typhoid  in  infants  have  been  overlooked,  and,  personally,  I  believe 
this  to  be  the  case,  then  many  of  these  cases  were  mild  in  type,  which 
tends  to  make  the  prognosis  more  favorable.  The  infection  in  fatal 
cases  in  infants  is  general  in  character — not,  as  m  older  children, 
largely  intestinal — and  the  temperature  curve  is  not  so  regular  and 
characteristic  as  in  the  older  child  and  adult. 

In  infants  the  average  duration  of  the  fever  is  not  more  than  two 
weeks.  Diarrhea  is  more  common  in  the  early  part  of  the  disease, 
and  vomiting  with  loss  of  appetite  is  not  an  unusual  early  symptom. 
Weakness  and  prostration  are  common,  but  epistaxis  seldom  appears. 
While  the  infant  may  be  drowsy  and  dull,  convulsions  are  rare.  The 
tongue  is  coated,  and  not  apt  to  be  dry.  Sore  throat  occurs  in  a  fan* 
proportion  of  the  cases.  Abdominal  distention  is  the  rule.  Bronchitis 
is  usually  present,  but  not  severe.  The  pulse  is  often  rapid  and  weak, 
but,  as  a  rule,  the  circulation  is  well  maintained.  The  infant  is  rest- 
less and  fretful,  but  rarely  has  any  other  marked  nervous  symptom. 


620 


THE  SPECIFIC  INFECTIOUS  DISEASES 


The  fever  rises  rapidly,  usually  reaches  the  maximum  in  four  or 
five  days,  remaining  high  for  seven  or  eight  days,  and  returns  to  nor- 
mal by  a  rapid  decline  or  a  more  gradual  fall  in  from  four  to  seven 
days.  The  rash  is  seen  in  about  70  per  cent,  of  the  cases.  It  may 
appear  earlier  than  in  later  childhood,  its  development  on  the  fifth, 
sixth  or  seventh  day  being  not  uncommon.  The  spleen  is  usually 
enlarged,  often  after  the  fifth  day.  A  positive  Widal  reaction  is 
obtained  in  90  per  cent,  of  the  cases.  The  leukocyte  count  is  low, 
ranging  from  4000  to  12,000.  The  urine  may  show  albumin,  and 
occasionally  hyalin  and  granular  casts,  especially  in  the  severe  cases. 


DAY  OF 
DISEASE 

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RESP. 

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Fig.  66. — Typhoid  fever  in  a  child  two  years  of  age. 


Typhoid  Fever  in  the  Older  Child. — Fever. — The  first  stage  shows 
a  fever  higher  each  morning  than  the  preceding  morning,  and  an 
evening  fever  higher  each  evening  than  the  preceding  evening.  In 
the  second  stage  the  fever  remains  more  or  less  continuously  high, 
with  a  morning  fall  of  1.5°  to  2.5°,  and  an  evening  rise  of  about 
the  same  extent.  In  the  third  stage  the  temperature  gradually 
returns  to  normal,  the  morning  temperature  being  lower  than  the 
evening,  and  reaching  normal  several  days  before  the  evening  tem- 
perature.    The  average  duration  is  eighteen  to  twenty-one  days. 

In  the  so-called  abortive  cases  the  duration  may  be  much  less; 
yet,  again,  the  fever  may  continue  for  four  or  five' weeks.  The  usual 
height  of  the  fever  is  102°  to  103°  F.,  but  high  temperatures  of  104° 
to  106°  F.  are  not  uncommon.  Increased  fever  often  apparently  pro- 
duces no  special  increase  in  the  symptoms.  The  temperature  may 
remain  subnormal  during  the  first  two  or  three  days  of  convalescence. 
A  sudden  and  marked  fall  in  temperature  usually  means  intestinal 
hemorrhage  or  perforation.  With  intestinal  hemorrhage  the  pulse  is 
weak,  the  face  pale,  and  the  extremities  cold.  With  perforation  there 
may  be  localized  abdominal  pain  which  increases,  also  increasing 
tenderness,  rigidity  of  the  abdominal  muscles,  vomiting,  and  collapse. 

Pulse. — The  pulse,  as  a  rule,  is  only  moderately  increased,  and  is 
slower  than  in  other  diseases  with  the  same  temperature.     It  may. 


TYPHOID  FEVER 


621 


however,  be  rapid  and  dicrotic.  It  is  not  as  slow  in  proportion  to  the 
fever  as  in  adults,  a  pulse  rate  of  160  to  170  not  being  uncommon,  and 
not  necessarily^  a  sign  of  danger.  The  older  the  child  the  slower,  as 
a  rule,  the  pulse.  Dicrotism  is  often  observed.  As  the  pulse  is  not 
as  slow  in  proportion  to  the  fever  as  it  is  in  the  adult  it  is  of  less 
assistance  in  forming  a  diagnosis. 

A  murmur,  systolic  in  time  and  heard  best  at  the  apex,  is  not  uncom- 
mon tow^ard  the  end  of  the  third  week.  It  is  temporary  in  character 
and  disappears  after  the  patient  has  entirely  recovered  from  the 
illness.  Myocarditis  may  be  the  cause  of  the  murmur,  or  it  may  be 
hemic.  By  acting  on  the  pneumogastric  centre  the  toxins  may  possibly 
affect  the  pulse,  and  by  their  action  on  the  heart  muscle  produce  the 
murmur. 


DISEASE 

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Fig.  67. — Typhoid  fever  in  a  child  seven  years  of  age. 


Bowels. — Constipation  may  be  present,  especially  in  younger 
children,  but  there  is  slight  diarrhea  in  about  50  per  cent,  of  all  the 
patients.  The  stools  are  not  characteristic.  Severe  diarrhea  is  uncom- 
mon except  in  the  worst  cases,  and  intestinal  hemorrhage  occurs  in 
only  about  2  or  3  per  cent,  of  the  cases,  and  is  most  often  seen  at  the 
end  of  the  second  week.  The  mortality  after  hemorrhage  is  about 
50  per  cent.  Hemorrhage  is  uncommon  in  children  under  ten  years 
of  age. 

Perforation  rarely  occurs,  but,  when  this  dangerous  symptom 
develops,  the  life  of  the  patient  usually  depends  upon  its  immediate 
recognition.  With  perforation  we  have  a  sudden  fall  in  temperature, 
sudden  abdominal  pain,  and  changes  in  the  respiration  and  pulse. 
The  pain  continues,  there  is  tenderness  with  some  rigidity  of  the 
abdominal  muscles,  and  there  may  be  vomiting  and  sweating.  The 
movements  of  the  abdomen  on  respiration  are  restricted,  there  is 
decrease  in  the  area  of  liver  dulness,  with  movable  dulness  in  the 
flanks,  and  leukocytosis. 

Abdominal  distention  is  present  in  70  per  cent,  of  the  cases,  more 
often  in  older  children.    Abdominal  pain  and  tenderness  seldom  appear, 


622  THE  SPECIFIC  INFECTIOUS  DISEASES 

although  vomiting  is  a  common  early  symptom  in  the  younger  child. 
Diarrhea  is  often  seen  in  the  severe  cases. 

Tongue. — The  tongue  is  not  so  dry  as  in  adults,  is  usually  coated 
early  in  the  disease,  the  edges  and  tip  being  clean. 

Rash. — Rose-colored  spots  appear  in  over  60  per  cent,  of  the  cases, 
being  scattered  over  the  abdomen,  chest,  back,  and  thighs.  The 
number  of  spots  is  less  than  in  adults.  They  usually  develop  at  about 
the  seventh  to  the  nmth  day,  coming  in  crops,  which  last  about  ten 
days.  They  are  of  great  diagnostic  importance,  and  usually  reappear 
in  a  relapse. 

Slileen. — ^The  spleen  is  enlarged  in  almost  all  cases,  this  enlargement 
being  demonstrated  by  palpation  or  percussion  in  about  80  per  cent, 
of  typhoid  children.  A  decrease  in  the  size  of  the  spleen  is  a  favorable 
sign,  and  usually  means  that  the  child  is  progressing  favorably.  An 
enlarged  spleen  that  does  not  decrease  in  size  indicates  the  continuance 
of  the  infection  and  persistence  of  the  disease.  During  a  relapse  the 
spleen,  as  a  rule,  enlarges. 

Lungs. — Bronchitis  is  so  often  present  that  it  may  justly  be  con- 
sidered a  normal  part  of  the  disease.  Bronchopneumonia  is  an 
unfavorable  complication,  especially  in  delicate  children  and  in 
hospital  cases.  Lobar  pneumonia  and  pleurisy  are  seen  occasionally; 
lung  abscess  is  rare. 

Headache. — Headache  is  present  in  SO  per  cent,  of  the  cases,  and  is 
usually  complained  of  by  children  old  enough  to  describe  their  symp- 
toms. Vertigo  is  less  common,  appearmg  in  about  20  per  cent,  of 
cases. 

The  Nervous  System.— T)^\smva.  in  mild  form  is  common;  in  the 
severe  cases  it  may  be  marked.  Dulness  is  especially  apt  to  be  seen 
in  the  younger  children.  True  meningitis  is  rare,  although  a  menin- 
gitis due  to  the  typhoid  bacillus  may  occur.  Post-typhoidal  temporary 
insanity  occasionally  develops,  in  the  mild  form  is  not  uncommon, 
and  is  seen  especially  in  those  children  whose  nutrition  is  poor,  and 
who  take  a  subnormal  amount  of  nourishment;  it  may  also  be  toxic 
in  origin.    It  usually  ends  in  complete  recovery. 

Delusions  of  fear  are  common,  or  the  child  may  become  greatly 
excited  on  the  slightest  cause,  or  may  be  greatly  depressed  mentally. 
The  nervous  symptoms,  as  a  rule,  improve  in  proportion  to  the  possi- 
bility of  increasing  the  child's  food.  Chorea  and  neuritis  occasionally 
appear,  and  paralysis  may  develop  in  those  muscles  supplied  by  the 
affected  nerves. 

Convulsions  are  dangerous  and  often  a  cause  of  death.  Hemiplegia 
is  a  rare  complication,  but  may  be  caused  by  embolism  or  thrombosis. 
In  severe  and  protracted  cases  the  mental  powers  may  be  more  or 
less  impaired,  and  melancholia,  various  degrees  of  mental  excitation 
or  depression,  or  temporary  dementia  may  develop.  The  tendency 
of  these  conditions  is  to  end  in  complete  recovery,  except  where  there 
are  permanent  brain  lesions,  as  in  some  cases  of  hemiplegia.  Epistaxis 
is  less  common  than  in  adults,  occurring  in  about  20  per  cent. 


TYPHOID  FEVER  623 

Kidneys. — Degenerative  changes  of  mild  degree  probably  occur  in 
most  cases.  At  the  height  of  the  disease  a  trace  of  albumin  is  detected 
in  the  urine,  and  occasionally  a  few  casts.  Typhoid  bacilli  are  found 
in  the  urine  in  from  20  to  50  per  cent,  of  the  cases.  Ehrlich's  diazo- 
reaction  in  the  urine  occasionally  appears  as  early  as  the  fifth  day, 
although  the  usual  time  is  from  the  seventh  to  the  tenth  day;  or 
it  may  not  appear  until  the  end  of  the  fifth  or  sixth  week,  consequently 
it  may  appear  before  or  after  the  Widal.  It  is  absent  in  about  15  per 
cent,  of  all  cases. 

Blood. — The  leukocytes  are  reduced  in  typhoid  fever,  leukopenia 
being  the  rule.  In  10  per  cent,  of  the  cases  the  white  cells  are  5000 
or  less;  in  70  per  cent.,  5000  to  10,000;  in  30  per  cent.,  10,000  to 
16,000.  If  leukocytosis  exists,  it  is  usually  due  to  some  complication. 
As  the  disease  progresses  secondary  anemia  develops,  both  the  red 
cells  and  the  hemoglobin  being  diminished,  and  during  convalescence 
the  red  cells  return  to  the  normal  more  rapidly  than  does  the  hemo- 
globin. 

Blood  cultures  are  of  great  assistance  in  a  case  of  doubtful  diagnosis. 
The  younger  the  child  the  more  difficult  it  is  to  locate  and  puncture 
the  vein,  but  those  who  have  mastered  the  technic  have  comparatively 
little  trouble  in  obtaining  from  |  to  2  c.c.  of  blood  by  puncturing  a 
vein  in  the  arm.  Busquer  recovered  the  typhoid  bacillus  in  43  chil- 
dren he  examined,  and  Rotch  and  Conrodi  have  also  proven  the 
efficacy  of  this  means  of  diagnosis.  The  Widal  reaction  is  of  great 
diagnostic  importance,  and  is  present  in  95  per  cent,  of  children  with 
typhoid  fever.  It  is  present  in  13  per  cent,  by  the  seventh  day;  in 
63  per  cent,  by  the  fifteenth  day;  and  in  89  per  cent,  by  the  twenty- 
fifth  day.  Occasionally  it  is  not  present  until  the  patient  is  entirely 
free  from  all  typhoid  symptoms.  In  children  with  jaundice  there  is 
a  positive  Widal,  hence  in  a  case  of  jaundice  the  Widal  loses  its 
significance. 

Relapses. — The  number  of  relapses  varies  in  different  epidemics. 
In  some  years  it  may  be  only  4  per  cent.,  in  others,  15  per  cent.  In 
my  own  cases  it  has  been  9  per  cent.  The  duration  of  the  relapse 
is  usually  about  fifteen  days;  ordinarily  it  is  shorter  than  the  original 
attack.  In  a  relapse  the  spleen  is  enlarged,  the  roseola  is  present  in 
75  per  cent,  of  the  cases,  leukopenia  in  60  per  cent.,  and  mild  intestinal 
symptoms  in  about  one-half  the  cases. 

Diagnosis. — In  the  diagnosis  of  a  doubtful  case  of  typhoid  fever, 
the  temperature,  rose  spots,  enlarged  spleen,  Widal  reaction,  blood 
cultures,  Ehrlich's  diazo-reaction,  typhoid  bacilli  in  stools  and  urine, 
and  the  intestinal  symptoms,  are  all  worthy  of  careful  study.  Usually 
the  diagnosis  is  easy,  occasionally  it  is  difficult,  but  it  is  almost  always 
possible  to  decide  positively  whether  typhoid  is  present  or  not. 

Differential  Diagnosis. — Appendicitis. — ^A  child  may  be  taken  sud- 
denly ill  with  severe  pain  in  the  right  iliac  fossa,  high  fever,  vomiting, 
and  often  little  or  no  resistance  of  the  abdominal  walls.  The  early 
subsidence  of  the  symptoms  in  the  region  of  the  appendix,  the  appear- 


624  THE  SPECIFIC  INFECTIOUS  DISEASES 

ance  of  rose  spots,  enlarged  spleen,  and  a  positive  Widal  clear  the 
diagnosis.  Yet  in  a  case  of  typhoid  fever,  a  typhoid  ulcer  in  the 
appendix  may  cause  a  perforation. 

Paratyphoid  Fever. — The  symptoms  are  very  like  those  of  typhoid 
fever,  but  usually  less  severe  and  of  shorter  duration.  The  paratyphoid 
bacillus,  which  may  be  found  in  the  stools,  urine,  and  blood,  differs 
only  slightly  from  the  typhoid  bacillus,  and  an  agglutination  of 
paratyphoid  cultures  occurs  with  the  blood  of  the  child  with  para- 
thyphoid.   There  is  no  Widal  reaction. 

Acute  Miliary  Tuberculosis. — In  this  disease  the  onset  is  slower 
than  in  typhoid.  There  may  be  a  family  history  of  tuberculosis,  or 
a  history  of  the  child's  exposure  to  tubercular  infection.  A  preced- 
ing pneumonia,  pertussis,  or  measles,  with  incomplete  recovery  is 
suspicious.  Cough,  irregular  fever,  and  nervous  symptoms  may  be 
present  in  both,  and  in  miliary  tuberculosis  the  physical  signs  in  the 
lungs  are  not  usually  significant. 

The  presence  of  tuberculous  lymph  glands,  a  persistent  cough,  grad- 
ually increasing  physical  signs  in  the  lungs,  the  appearance  of  tubercles 
in  the  choroid,  a  positive  tuberculin  test,  and  the  finding  of  tubercle 
bacilli  in  the  mucus  removed  from  the  pharynx,  will  confirm  the 
diagnosis  of  tuberculosis.  A  positive  Widal,  rose  spots,  and  typhoid 
bacilli  in  the  stools,  urine,  or  blood  make  certain  the  diagnosis  of 
typhoid. 

Prognosis. — The  mortality  varies  in  different  epidemics  according 
to  the  severity  of  the  infection,  the  general  health  and  vitality  of  the 
child,  and  whether  it  comes  under  observation  early  or  late  in  the 
disease.  In  hospitals  the  mortality-rate  is  about  8  pef  cent.;  in 
private  practice  4  per  cent.  The  prognosis  is,  of  course,  influenced 
by  all  complications,  in  direct  proportion  to  their  mildness  or  severity. 
In  my  experience,  most  of  the  deaths  were  associated  with  complica- 
tions, such  as  bronchopneumonia,  hemorrhage,  or  perforation.  The 
prognosis  is  really  better  than  is  apparent  from  statistics,  as  mild 
cases  of  typhoid  are  easily  overlooked.  A  continued  fever  in  a  child 
should  always  suggest  the  possibility  of  typhoid  fever,  and  a  system- 
atic examination  for  typhoid  in  all  such  cases  is  the  onl}'  method  by 
which  one  can  avoid  error. 


Number  of  Deaths  in  Phil 

\DELPHIA— 

-Typhoid 

Fever. 

Age  period. 

1911. 

1912. 

1913. 

1914. 

1915 

Under  1  year 

0 

0 

0 

0 

0 

1  to    2  years 

4 

3 

2 

1 

0 

2  to    5      "          .      . 

10 

7 

10 

5 

2 

5  to  10      "          .      . 

14 

7 

13 

8 

5 

10  to  15      " 

15 

18 

17 

12 

13 

15  to  20      "    .      .      . 

24 

29 

26 

17 

19 

All  ages     .... 

223 

200 

255 

124 

109 

Complications. — Among  the  more  common  complications  may  be 
mentioned  otitis,  pneumonia,  diphtheria,  hemorrhages,  furunculosis, 
and  nephritis.     Among  the  rarer  complications  are  measles,  scarlet 


TYPHOID  FEVER  625 

fever,  gangrene  of  the  skin,  chorea,  and  neuritis.  Aphasia  is  more 
common  in  children  than  in  adults,  and  usually  appears  in  the  third 
week  in  severe  cases  associated  with  nervous  symptoms.  It  ordinarily 
ends  in  complete  recovery  in  three  or  four  weeks.  Meningitis  may  be 
due  to  the  typhoid  bacillus,  and  may  end  in  recovery. 

Treatment. — Prophylaxis  is  of  the  greatest  importance;  and,  as  the 
drinking  of  infected  water  is  the  most  common  cause  of  the  disease, 
it  is  wise  to  order  that  all  drinking  water,  and  water  used  for  washing 
such  vegetables  as  celery  or  cress,  be  boiled.  If  a  case  of  typhoid 
fever  exists  on  a  dairy  farm,  milk  from  such  a  farm  should  not  be 
allowed  to  be  sold.  An  infant  should  be  weaned  if  its  mother  has 
typhoid,  and  all  children  who  are  apt  to  be  exposed  to  typhoid  fever 
infection  may  be  protected  by  typhoid  vaccine.  The  feces  and  urine 
of  a  typhoid  child  should  be  disinfected  by  covering  them  with  three 
times  their  bulk  of  1  to  20  carbolic  acid,  or  1  to  1000  bichloride 
solution. 

All  dishes,  spoons,  etc.,  should  be  similarly  treated  with  1  to  20 
carbolic  acid,  and  all  bed  linen  should  be  soaked  in  1  to  20  carbolic 
solution,  and  then  well  boiled.  All  typhoid  cases  should,  if  possible, 
be  kept  apart  from  both  well  and  sick  children,  as  it  is  not  uncommon 
for  those  who  handle,  nurse,  or  come  in  intimate  contact  with  typhoid 
cases  to  contract  the  disease.  The  hands  of  the  nurse,  especially, 
are  in  danger  of  being  contaminated  by  the  fecal  or  urinary  discharges, 
and  infection  thus  take  place;  therefore,  the  hands  of  all  who  come 
in  contact  with  typhoid  cases  should  frequently  be  washed  in  a  solu- 
tion of  lysol,  1  to  200,  particularly  before  eating. 

The  child  should  be  kept  in  bed,  in  a  large,  well-ventilated  room, 
until  the  temperature  has  been  normal  for  a  week. 

Diet. — Nourishment  should  be  given  every  three  hours  during  the 
day  and  every  three  or  four  hours  during  the  night.  The  nourish- 
ment should  be  liquid,  milk  being  the  best  single  article  of  diet,  and 
this  should  be  administered  in  such  quantities  and  such  dilutions  as 
the  child  can  digest.  It  may  be  diluted  with  water,  or  barley-water, 
and,  if  not  well  digested,  should  be  peptonized.  If  the  symptoms  of 
gastro-ifttestinal  infection  are  present,  milk  is  contra-indicated  until 
the  acute  symptoms  have  subsided. 

Mutton,  beef,  and  chicken  broths  may  be  given  in  addition  to  the 
milk,  and  albumen-water  is  often  well  borne  and  answers  a  useful 
purpose.  A  raw  egg,  either  alone  or  beaten  up  with  milk,  is  very 
nourishing,  especially  in  the  early  stages  of  convalescence.  Cereal 
gruels,  thoroughly  cooked  and  well  thinned  with  milk,  may  be  given 
throughout  the  illness. 

If  the  disease  runs  the  regular  course  of  about  three  weeks,  milk, 
animal  broths,  and  cereal  decoctions  with  milk  are  all  that  is  required. 
If,  however,  the  fever  continues  for  four,  five,  or  six  weeks,  yet  no 
relapse  has  occurred,  and  especially  if  there  is  extreme  prostration 
with  emaciation,  but  no  marked  symptom  of  gastro-intestinal  infec- 
tion, raw  eggs,  or  soft  eggs,  junket,  and  custards  may  be  added  to  the 
40 


626  THE  SPECIFIC  INFECTIOUS  DISEASES 

diet.  After  the  temperature  has  been  normal  for  one  week,  milk  toast, 
scraped  meat,  zweibach,  and  soft  foods  may  be  allowed.  Water 
should  be  given  freely  throughout  the  disease. 

Hydrotherapy. — If  the  child's  temperature  remains  below  103°  F., 
a  morning  and  evening  sponge  with  water  at  90°  F.,  followed  by  an 
alcohol  rub,  is  all  that  is  required.  The  best  method  of  treating 
pyrexia  and  the  associated  nervous  and  respiratory  disturbances  is 
by  the  bath.  The  temperature  of  the  water  should  be  90°  to  85°  F., 
and  the  child  should  remain  in  the  tub,  its  entire  body,  except  the 
head,  being  covered  by  the  water,  from  five  to  twelve  minutes.  Fric- 
tion of  the  body  and  sponging  of  the  head  should  be  kept  up  throughout 
the  time  of  the  bath. 

The  length  of  the  bath  depends  upon  the  effect  produced  on  the 
temperature,  and  the  nervous  and  respiratory  symptoms.  After  the 
bath  the  child  should  be  well  rubbed  and  returned  to  its  bed.  The 
rectal  temperature  should  be  taken  ten  minutes  after  the  bath,  and 
the  reduction  in  the  fever  will  serve  as  a  guide  in  deciding  upon  the 
duration  of  future  baths,  and  the  temperature  of  water  to  be  employed. 
If  there  is  prostration,  whisky,  in  doses  appropriate  to  the  age  of 
the  child,  may  be  given  before  and  after  bathing. 

The  bath  should  be  repeated  every  three  to  six  hours  if  the  tem- 
perature remains  at  103°  F.  or  higher,  and  an  ice-cap  applied  to  the 
head  is  often  beneficial  in  those  cases  where  the  temperature  remains 
high  and  the  nervous  symptoms  marked.  Bromide  of  soda,  5  grains, 
repeated  in  three  hours  if  necessary,  is  of  assistance  in  quieting  the 
nervous  symptoms  and  inducing  sleep.  Cold-water  baths  are  not 
well  borne  by  children  with  typhoid,  and,  in  my  experience,  the  water 
should  never  be  below  80°  F. 

Bowels. — During  the  first  few  days  of  the  disease  constipation  may 
be  overcome  by  fractional  doses  of  calomel,  and  while  the  fever  con- 
tinues it  may,  if  marked,  be  partially  relieved  by  an  occasional  dose 
of  castor  oil.  The  safest  and  best  means  of  overcoming  this  condi- 
tion is  by  the  daily  use  of  an  enema  of  salt  solution,  soap  and  water, 
or  small  amounts  of  sweet  oil.  If  the  number  of  stools  in  twenty-four 
hours  exceeds  four,  especially  if  they  are  large  and  watery,  it  is  well 
to  control  the  diarrhea  by  subnitrate  of  bismuth,  5  to  10  grains,  every 
three  or  four  hours,  and  in  older  children,  1  to  2  grains  of  salol  may  be 
added  to  each  bismuth  dose.  The  bismuth  and  salol  are  only  to  be 
given  as  long  as  the  diarrhea  continues.  Paregoric,  10  to  20  drops, 
may  be  given  in  addition  to  the  bismuth  if  the  diarrhea  is  not  easily 
checked,  the  dose  being  in  proportion  to  the  age  of  the  patient  and 
the  severity  of  the  diarrhea. 

The  stools  should  always  be  carefully  examined,  as  the  presence  of 
undigested  food  materials  may  be  of  service  in  the  selection  of  the 
diet  to  be  given.  Tympanites  is  best  controlled  by  a  hot  turpentine 
stupe  applied  to  the  abdomen  and  covered  by  oiled  silk  and  the  giving 
of  a  warm  enema  of  salt  solution.  If  this  does  not  afford  relief,  a 
rectal  tube  may  be  cautiously  used. 


PARATYPHOID  FEVER  627 

Alcohol. — Whisky  is  not  required  in  the  mild  cases.  In  the  asthenic 
cases  whisky,  20  drops  to  1  dram,  may  be  given  every  three  hours; 
it  is  especially  valuable  when  there  is  low  muttering  delirium  and  a 
weak  pulse.  Strychnine  and  camphor  are  of  benefit  when  the  heart- 
sounds  are  weak,  or  if  a  murmur  develops  due  either  to  changes  in 
the  myocardium  or  to  general  toxemia. 

Hemorrhage  from  the  bowel  demands  absolute  rest  for  the  patient, 
an  ice-coil  to  the  abdomen,  sufficient  opium  by  the  mouth  to  check 
intestinal  peristalsis  and  bowel  movements,  the  stopping  of  all  food, 
and  the  giving  of  only  small  pieces  of  ice  or  very  small  amounts  of 
water  by  mouth.  Parotitis  is  best  treated  by  the  application  of  an 
ice-bag.  Perforation  demands  the  opening  of  the  abdomen,  and  the 
closing  of  the  perforation  in  the  intestine.  An  early  diagnosis  of  per- 
foration is  essential  if  the  child's  life  is  to  be  saved. 

PARATYPHOID   FEVER. 

Paratyphoid  fever  in  many  cases  bears  a  close  resemblance  clinically 
to  typhoid  fever,  but  it  is  due  to  an  entirely  different  organism.  In 
paratyphoid  there  are  no  intestinal  lesions. 

Etiology. — The  organisms  which  cause  the  disease  are  called  para- 
typhoid bacilli,  and  are  divided  into  two  groups,  "A"  and  "B," 
according  to  their  cultural  characteristics.  Many  cases  of  paratyphoid 
fever  are  the  result  of  food  poisoning,  and  there  is  considerable  evidence 
also  to  show  that  it  is  a  water-borne  disease. 

Symptoms. — The  symptom-complex  is  practically  the  same  as  in 
typhoid  fever;  the  disease  may  occur  in  epidemics,  and  is  not  uncom- 
mon. It  may  be  differentiated  from  typhoid  fever  by  a  negative 
Widal  reaction  which,  however,  is  only  obtained  when  the  tested 
blood  is  diluted  more  than  1  part  in  50.  The  paratyphoid  organisms 
cause  an  agglutinin  reaction,  but  belong,  according  to  their  cultural 
and  other  characteristics,  between  the  typhoid  bat:illus  and  the 
Bacillus  coli  communis.  The  symptoms  are  usually  less  severe  than 
in  typhoid,  but  one  may  observe  nosebleed,  headache,  and  anorexia; 
the  temperature  may  be  about  101°  F.  at  first,  and  so  continue  for 
two  weeks,  rising  a  degree,  to  102°  F.,  every  day,  and  falling  the 
next  morning.  In  some  cases  the  symptoms  closely  resemble  Asiatic 
cholera,  and  there  is  little,  if  any,  evidence  to  suggest  t^,^hoid.  The 
spleen  is  usually  enlarged,  but  Peyer's  patches,  the  mesenteric  glands, 
and  solitary  follicles  are  not  involved.  In  the  worst  cases  the  symptoms 
are  largely  those  of  septicemia. 

Diagnosis. — The  diagnosis  is  made  by  examination  of  the  blood, 
which  gives  a  positive  agglutination  reaction  with  the  paratyphoid 
bacillus. 

Prognosis. — The  prognosis  is  usually  favorable,  and  death  occurs 
only  in  the  most  severe  cases. 

Treatment. — The  treatment  is,  for  the  most  part,  the  same  as  in 
typhoid  fever. 


628-  THE  SPECIFIC  INFECTIOUS  DISEASES 

SCARLET  FEVER  (SCARLATINA). 

Scarlet  fever  is  an  acute  contagious  disease,  occurring  sporadically 
or  in  epidemics.  It  is  characterized  by  sudden  onset,  sore  throat, 
a  punctate  eruption,  scarlet  in  color,  which  covers  the  entire  body, 
and  is  followed  by  desquamation  of  large  flakes  of  superficial  skin. 
There  is  a  tendency  to  otitis,  cervical  adenitis,  and  nepliritis. 

Etiology. — The  disease  is  essentially  one  of  children.  It  is  rarely 
met  with  in  infants  under  six  months  of  age,  and  is  uncommon  even  in 
children  from  six  to  twelve  months.  Numerous  instances  have  been 
reported  where  the  mother  havmg  scarlet  fever  continued  to  nm-se 
her  infant  under  six  months  of  age,  and  the  child  did  not  contract  the 
disease. 

A  very  few  cases  of  infants  being  born  with  scarlet  ievev  are  on 
record,  the  mother  having  the  disease  at  the  time  of  the  infant's 
bu-th.  After  the  age  of  one  year  the  susceptibility  to  the  disease 
increases  with  each  year  until  the  extreme  is  reached  at  five  or  six 
years;  after  this  age  the  number  of  cases  gradually  decreases  and  it 
is  uncommon  after  the  sixteenth  year.  It  is  occasionally  seen  in  adult 
life,  but  after  the  period  of  childhood  is  passed  the  disease  is  usually 
in  a  mild  form. 

In  Philadelphia  during  the  years  1911  to  1915  inclusive  only  18 
deaths  occurred  from  scarlet  fever  in  children  under  one  year  of  age. 
]More  than  60  per  cent,  of  the  cases  occur  in  children  under  five  years 
of  age,  and  90  per  cent,  in  the  first  ten  years  of  life.  Unlike  measles, 
immunity  in  adult  life  does  not  depend  upon  the  fact  that  most 
children  contract  the  disease,  as  it  is  estimated  that  not  more,  and 
probably  less,  than  50  per  cent,  of  children  have  scarlet  fever. 

Second  attacks  are  rare.  Family  predisposition  to  contract  scarlet 
fever  is  occasionally  observed,  and  not  only  may  all  children  in  the 
family  contract  the  disease,  but  it  may  appear  in  them  in  a  most 
severe  form,  while  the  other  cases  seen  at  the  time  may  be  of  quite 
a  mild  type.  It  is  more  common  in  the  winter  months,  possibly  because 
children  are  kept  indoors  more,  and  are  brought  more  often  and  more 
closely  in  intimate  contact. 

Epidemics  differ  greatly  in  severity  and  in  the  liability  to  dangerous 
complications.  It  is  more  common  in  city  than  in  country  districts, 
and  the  white  race  is  more  susceptible  and  shows  a  greater  mortality 
than  the  colored  race. 

The  specific  virus  of  scarlet  fever  is  as  yet  unknown.  The  immunity 
that  one  sees  so  often  in  those  exposed  to  scarlet  fever  is  not  always 
permanent,  as  a  child  who  has  been  brought  in  close  contact  with 
a  scarlet  fever  patient  may,  if  afterward  exposed,  contract  the  dis- 
ease. The  virus  is  present  in  the  discharge  from  the  nose,  mouth, 
and  ears,  and  while  this  dried  discharge  containing  the  poison  may  be 
carried  for  short  distances  by  the  air,  it  cannot  be  carried  far,  as 
those  children  living  in  the  neighborhood  of  scarlet  fever  hospitals 
do  not  show  an^'  unusual  tendencv  to  contract  the  disease. 


SCARLET  FEVER  629 

Scarlet  fever  has  been  produced  in  children  by  inoculation  with  the 
mucus  from  the  mouth  and  throat,  also  by  the  blood  and  contents 
of  the  vesicles,  so  that  undoubtedly  the  virus  producing  the  disease 
must  be  present  in  these  fluids. 

It  is  still  a  matter  of  doubt  as  to  whether  it  is  possible  to  produce 
scarlet  fever  by  inoculating  a  child  with  the  scales;  the  evidence  is 
against  the  possibility  and  probability  of  the  disease  being  trans- 
ferred by  such  inoculations.  The  poison  lives  for  long  periods  of 
time  outside  the  human  body,  and  may  remain  virulent  and  cling 
to  the  bed  linen,  carpets,  wall  paper,  and  any  portion  of  the  room 
for  months,  in  spite  of  the  miOst  thorough  scrubbing,  disinfecting,  and 
flushing  wdth  fresh  air. 

The  disease  is  usually  spread  by  direct  personal  contact.  The 
mild  cases  are  especially  to  be  feared  as  sources  of  infection,  as  they 
may  not  be  ill  enough  to  go  to  bed,  and  may  even  contmue  to  attend 
school;  they  are  consequently  brought  in  close  contact  with  a  large 
number  of  well  children,  and  may  easily  transmit  the  disease. 

Epidemics  have  been  traced  to  milk,  and  boiling  the  milk  destroys 
the  scarlet  fever  poison.  While  the  lower  animals  do  not  contract 
the  disease,  a  pet  cat  or  dog  may  carry  the  poison  from  the  sick-room 
to  children  in  the  same  or  near-by  house. 

The  disease  may  be  carried  by  a  third  person,  and  all  persons 
coming  in  contact  with  a  scarlet  fever  patient,  especially  the  nurse 
and  physician,  should  take  definite  precautions  to  avoid  carrying  the 
infection.  Numerous  instances  have  been  reported  where  the  disease 
has  been  known  to  be  conveyed  considerable  distances  by  letters 
or  packages  sent  by  mail. 

The  scarlatinal  poison  enters  the  body  through  the  nose  and  throat; 
less  often  through  wounds  and  burns,  and  in  puerperal  women 
through  the  genital  tract,  although  it  is  certain  that  many  of  the 
so-called  cases  of  scarlet  fever  in  puerperal  women  have  been  puer- 
peral sepsis  and  not  scarlet  fever. 

The  streptococcus  is,  by  some,  considered  the  cause  of  the  disease, 
and  streptococci  have  been  found  in  the  blood,  skin,  and  in  the  internal 
organs  at  autopsy.  The  general  belief  is  that  while  the  streptococcus 
may  and  often  does  exist  as  a  mixed  infection,  and  does  produce 
many  of  the  dangerous  symptoms  and  complications  of  scarlet  fever, 
as  pseudomembrane  in  the  pharynx,  otitis,  cervical  adenitis,  endo- 
carditis, synovitis,  and  nephritis,  that  it  is  present  only  as  a  compli- 
cation, and  is  not  the  true  cause  of  the  disease. 

A  protozoon  has  been  found  in  the  skin  by  Mallory,  and  the  belief 
that  the  disease  is  caused  by  a  protozoon  is  steadily  growing  in  favor. 
The  contagion  is  slight  in  the  beginning  of  scarlet  fever,  whereas 
in  measles  the  contagion  is  marked  from  the  very  beginning  of  the 
disease.  Scarlet  fever  is  very  contagious  during  the  eruption  and 
for  quite  a  long  time  after  the  eruption  has  disappeared,  but  it  is 
not  at  all  certain  that  the  contagion  is  due  to  the  skin  that  is  peel- 
ing off;  in  fact  many  believe  that  this  desquamating  epidermis  is 
incapable  of  producing  the  disease. 


630  THE  SPECIFIC  INFECTIOUS  DISEASES 

A  scarlet  fever  patient  can  transmit  the  affection  before  desquama- 
tion begins  and  after  it  has  ceased,  and  a  discharge  from  the  nose,  ear 
or  throat  persisting  after  desquamation  has  ceased  is  a  not  uncommon 
source  of  infection.  Nothing  is  more  common  than  for  a  scarlet 
fever  patient  to  be  released  or  escape  from  quarantine  before  desqua- 
mation is  complete,  and  as  the  general  belief  at  present  is  that  the 
contagion  is  contained  in  the  scales,  a  child  who  is  desquamating 
would,  if  the  scales  carry  the  contagion,  expose  to  the  disease  all  those 
with  whom  he  comes  in  contact. 

The  disease  is  especially  contagious  when  the  fever  is  high,  and  the 
throat  symptoms  severe,  and  is  more  or  less  contagious  as  long  as 
any  discharge  is  present  from  the  nose,  ears,  or  throat,  and  until 
desquamation  is  complete,  and  quarantine  m  an  ordinary  case  should 
continue  for  six  weeks.  Infected  articles  and  clothes  that  have  been 
kept  in  closed  drawers  and  closets  may  transmit  the  disease  months 
or  even  years  later. 

Measles,  whooping-cough,  chicken-pox,  diphtheria,  typhoid  fever, 
or  erysipelas,  may  coexist  with  scarlet  fever,  although  a  pseudomem- 
brane  in  the  pharynx  or  larynx  may  be  diphtheritic  or  streptococcic. 
It  is  estimated  that  from  2  to  4  per  cent,  of  the  scarlet  fever  cases 
discharged  from  the  hospital  transmit  the  disease  to  other  children. 
This  estimate  I  believe  is  too  small. 

Pathological  Anatomy. — In  an  uncomplicated  case  of  scarlet  fever 
pathological  changes  are  found  in  the  skin,  tongue,  throat,  and  the 
lymphatic  glands.  The  rash  disappears  after  death,  except  in  those 
locations  where  it  has  been  especially  marked  during  life.  If  the 
rash  is  of  the  hemorrhagic  form  it  is  visible  postmortem. 

The  skin  shows  a  marked  congestion  of  the  bloodvessels,  and  a 
dilatation  of  the  lymphatics  with  moderate  cellular  proliferation 
around  the  bloodvessels,  hair  follicles,  and  sweat  glands.  The 
epidermis  is  destroyed  and  is  later  thrown  of!  in  scales  or  flakes.  The 
tongue  shows  similar  changes  in  its  epithelium  to  that  occurring  in 
the  skin,  but  the  changes  occur  earlier  in  the  disease  and  are  more 
severe.  The  pharynx  shows  an  inflammation  which  may  be  of  a  mild 
catarrhal  form,  or  of  a  severe  type  with  pseudomembrane. 

The  anterior  and  posterior  nares  show  a  more  or  less  severe 
involvement  of  the  mucosa,  and  the  ears  are  not  infrequently  involved. 
The  infection  may  extend  from  the  nose  to  the  antrum  of  Highmore 
or  from  the  ear  to  the  mastoid  with  possible  involvement  of  the 
meninges,  and  later  of  the  brain. 

The  lymphatic  system  throughout  the  entire  body  is  involved  to 
a  marked  extent  in  scarlet  fever.  Xot  only  are  the  superficial 
lymphatics,  as  the  cervical,  axillary  and  inguinal,  enlarged,  but  the 
deeper  glands,  as  the  tracheal,  bronchial,  mesenteric,  and  retro- 
peritoneal, are  also  affected,  and  the  tonsils,  liver,  and  spleen  show 
a  distinct  hyperplasia.  The  cervical  lymphatics  may  undergo  sup- 
puration, and  the  infection  may  spread  to  the  surrounding  tissues, 
resulting  possibly  in  abscess,  and  rarely  gangrene. 


SCARLET  FEVER  631 

In  severe  cases  the  mucous  membrane  of  the  stomach  shows 
distinct  inflammatory  changes  and  similar  changes  are  found  in  the 
mucous  membranes  of  the  intestine  with  marked  swelHng  of  the 
lymph  folHcles. 

The  heart  may  show  either  cloudy  swelling  or  fatty  degeneration; 
less  commonly,  an  endocarditis  or  pericarditis  develops.  Hypertrophy 
and  dilatation  may  ensue  from  a  nephritis.  Bronchopneumonia  is  not 
uncommon  in  the  fatal  cases  and  a  seropurulent  pleurisy,  pulmonary 
gangrene,  and  abscess  may  occur.  Acute  interstitial  nephritis  is  the 
most  common  form  of  nephritis  associated  with  scarlet  fever,  and  in 
all  fatal  cases  more  or  less  marked  pathological  changes  in  the  kidneys 
are  found. 

Symptoms. — The  period  of  incubation  is  short,  usually  from  one 
to  seven  days;  commonly  the  disease  develops  within  two  to  four 
days  after  exposure.  The  shorter  the  incubation,  the  more  severe 
is^  as  a  rule,  the  attack. 

Stage  of  Invasion — ^The  child  is  taken  suddenly  ill  without  any 
prodromes;  vomiting  is  often  the  first  symptom.  The  vomiting  may 
occur  a  number  of  times  and  be  very  severe.  In  young  children,  a 
convulsion  is  not  uncommon,  and  very  occasionally  the  disease  may 
begin  with  a  chill.  Fever  is  present  from  the  first,  and  usually  reaches 
its  maximum  in  twenty-four  to  forty-eight  hours  and  may  even  in 
a  few  hours  rise  to  104°  or  105°  F.  The  higher  the  initial  fever,  the 
more  severe,  as  a  rule,  is  the  illness,  although  in  the  mild  cases  the 
temperature  may  not  exceed  101°  F. 

Sore  throat  is  an  early  symptom,  but  as  many  children  will  not 
complain  of  soreness  in  the  throat,  even  when  a  considerable  amount 
of  inflammation  is  present,  it  is  always  necessary  and  advisable  to 
make  an  examination  of  the  pharynx.  The -severity  of  the  inflam- 
mation, which  commonly  involves  the  soft  palate,  tonsils,  and 
pharynx,  with  small  red  points  on  the  hard  palate,  is  in  direct  pro- 
portion to  the  severity  of  the  infection. 

Headache  is  also  an  early  symptom,  and  the  severity  of  these 
initial  symptoms,  as  convulsions,  vomiting,  fever,  sore  throat,  and 
headache,  will  usually  be  sufficient  to  indicate  the  probable  severity 
or  mildness  of  the  future  course  of  the  disease. 

The  tongue  is  coated,  the  tip  and  edges  being  red,  the  child  refuses 
nourishment,  complains  of  thirst,  is  restless,  drowsy,  or  delirious, 
and  passes  only  small  amounts  of  high-colored  urine.  In  younger 
children,  especially  in  hot  weather,  diarrhea  may  occur. 

Stage  of  Eruption. — The  rash  appears  first  on  the  neck  and  chest, 
and  rapidly  spreads  over  the  body  and  face;  ordinarily  the  entire 
surface  of  the  body  is  covered  in  twenty-four  to  thirty-six  hours  after 
its  first  appearance.  The  rash  may  appear  on  the  face  only  as  a 
flush,  or  the  face  may  be  almost  or  quite  free  from  rash.  The  eruption 
usually  appears  in  the  first  twenty-four  to  forty-eight  hours,  although, 
rarely,  its  appearance  is  delayed  until  the  third,  fourth,  or  fifth  day. 

It  appears  first  as  very  small  red  points,  set  very  closely  together; 


632  THE  SPECIFIC  INFECTIOUS  DISEASES 

the  points  are  larger  and  not  so  close  together  on  the  legs.  The  rash 
areas  are  scattered  in  patches  over  the  body,  and,  spreading  quickly, 
cover  the  entire  surface.  The  general  color  of  the  skin  is  red,  and 
the  appearance  of  the  red  skin  and  innumerable  fine,  darker  red 
points  is  very  characteristic.  The  color  of  the  skin  is  usually  a  dull 
red,  and  becomes  dusky  red  as  it  fades. 

The  body  has  the  appearance  of  being  covered  with  a  rash  of 
uniform  reddish  color,  but  close  inspection  reveals  the  skin  to  be  a 
lighter  red,  and  the  fine  points  to  be  distinctly  darker.  Irregular 
patches  of  skin  on  the  buttocks,  arms  or  legs,  may  be  entirely  free 
from  rash,  giving  the  skin  a  blotchy  appearance  not  unlike  measles. 
The  face  may  be  entirely  free  from  rash,  but  usually  the  forehead 
and  cheeks  are  flushed.  The  lips,  also  alse  and  tip  of  the  nose,  are, 
as  a  rule,  free  from  rash,  giving  the  so-called  white  rim  around  the 
mouth  which  is  quite  characteristic.  The  rash  disappears  on  pressure, 
is  usually  accompanied  by  itching,  and,  if  severe,  edema  and  swelling 
are  present. 

In  the  mild  cases,  the  rash  may  be  very  slight,  may  only  appear 
over  very  small  areas,  may  not  even  show  itself  on  the  face,  is  most 
often  under  such  conditions  seen  in  the  axillae,  groins,  the  back  of 
the  thighs  or  buttocks,  and  in  these  locations  may  last  for  only  twenty- 
four  hours.  The  eruption  continues  at  its  height  for  twelve  to  forty- 
eight  hours,  and  lasts  usually  from  three  to  seven  days. 

A  careful  examination  of  the  skin  will  show  small  vesicles  to  be 
present  in  a  fair  proportion  of  cases,  and  especially  when  the  rash 
has  been  very  severe.  In  the  worst  cases  the  rash  often  varies,  not 
only  in  its  appearance,  but  also  in  the  time  of  its  development.  It 
may  be  of  a  dark,  almost  purple  color,  or  again  it  may  closely  resemble 
the  rash  of  measles.  If  the  eruption  is  very  faint,  a  hot  bath  may 
cause  it  to  better  develop. 

Stage  of  Desquamation. — Usually  within  forty-eight  hours  after  the 
rash  has  disappeared,  desquamation  begins.  It  appears,  as  a  rule,  first 
on  the  neck  and  chest,  and  the  entire  body  with  the  exception  of  the 
hands  and  feet  continues  to  shed  fine  bran-like  scales  for  about  two 
or  three  weeks.  The  peeling  appears  later  on  the  hands  and  feet, 
the  thicker  skin  of  the  palms,  fingers,  soles  and  toes  being  slower 
to  separate,  and  the  desquamation  continuing  for  a  longer  period  of 
time,  usually  about  four  or  five  weeks,  and  often  peeling  off  in  large 
flakes.  Occasionally  the  thickened  epidermis  of  the  fingers  or  palms 
may  separate  in  one  large  piece  like  the  ragged  finger  or  palm  of  a  glove. 
The  character  of  the  desquamation  is  often,  but  not  always,  in 
direct  proportion  to  the  intensity  of  the  rash,  being  quite  extensive 
and  flaky  in  the  severe,  and  slight  and  bran-like  in  the  mild  eruption. 
In  the  very  light  cases,  desquamation  should  be  looked  for  at  the  tips 
of  the  fingers,  under  the  nails,  and  in  the  groins  and  axilla^.  Desqua- 
mation may  occur  twice  in  one  or  more  portions  of  the  body,  prolonging 
the  period  of  quarantine.  Falling  of  the  hair  and  shedding  of  the 
nails  are  occasionallv  seen. 


SCARLET  FEVER  633 

Desquamation  is  the  most  typical  sign  of  scarlet  fever,  and  it  is 
not  uncommon  in  hospital  dispensaries  or  among  the  poor  to  see 
a  child  in  the  peeling  stage  of  scarlet  fever,  the  history  being  that 
a  mild  and  transient  rash  occurred  several  weeks  previously;  with 
this  history  and  desquamation,  scarlet  fever  can  be  positively 
diagnosed.  In  very  few  diseases  is  such  a  great  variation  seen  in 
the  severity  of  the  symptoms  as  appears  in  scarlet  fever.  Sudden 
onset,  fever,  sore  throat,  and  rash  are  present  to  a  greater  or  less 
degree  in  every  case,  but  in  the  light  cases  these  symptoms  may  be 
very  mild  and  even  pass  unnoticed. 

Diagnosis. — Frank  typical  scarlet  fever  offers  no  great  difficulty  in 
diagnosis,  since  it  can  easily  be  made  from  the  presence  of  the  more 
prominent  symptoms,  such  as  a  sudden  onset  accompanied  by  vomit- 
ing, a  rapid  rise  in  temperature,  the  appearance  of  the  tliroat,  enlarged 
papillae  on  the  tongue,  and  the  typical  eruption  appearing  within 
forty-eight  hours.  These  symptoms  constitute  an  unmistakable 
syndrome,  but  no  one  symptom  is  pathognomonic. 

A  diagnosis  can  rarely  be  made  before  the  eruption  appears;  on 
the  other  hand,  the  diagnosis  cannot  be  made  upon  the  appearance 
of  the  rash  alone,  since  many  other  eruptions  resemble  that  of  scarlet 
fever,  such  as  the  rash  in  rotheln,  diphtheria,  septic  erythema,  and 
influenza,  also  the  drug  rashes  and  antitoxin  rash. 

Scarlatiniform  erythemas  and  rashes  are  also  produced  by  severe 
burns,  intestinal  auto-intoxication,  measles,  varicella,  variola,  and  vac- 
cinia, also  in  rheumatism,  pyemia,  malaria,  and  typhoid  fever. 

In  attempting  to  decide  whether  a  rash  is  that  of  scarlet  fever  or 
not,  the  time  of  its  onset  and  its  persistence  are  important  points, 
and  the  amount  of  scaling  which  follows  a  rash  of  given  intensity  is 
greater  in  scarlet  fever  than  after  any  other  rash  which  might  simulate 
it.  Many  eruptions  cause  desquamation,  some  more  freely  than  scarlet 
fever;  but  well-marked  desquamation  after  an  illness  which  simulates 
scarlet  fever  is  a  point  of  great  diagnostic  value. 

In  making  a  diagnosis  after  the  eruption  has  faded  or  changed, 
a  white  line  at  the  junction  of  the  finger  with  the  nail  showing  begin- 
ning desquamation  is  of  great  value.  Another  important  clue  to  the 
diagnosis  is  an  accurate  history  of  the  diseases  the  child  has  previously 
had  and  the  diseases  to  which  it  has  been  exposed. 

Differential  Diagnosis. — While  the  throat  involvement  in  scarlet 
fever  may  suggest  diphtheria  at  first,  yet  the  eruption  which  appears 
usually  indicates  the  true  nature  of  the  disease,  and  the  prevalence 
of  one  or  the  other  of  these  diseases  is  also  confirmatory.  The  diag- 
nosis of  diphtheria  can,  as  a  rule,  be  made  with  absolute  certainty 
by  a  culture  from  the  throat,  and  this  test  should  always  be  made 
when  there  is  any  doubt. 

Measles. — The  typical  eruption  of  scarlet  fever  does  not  resemble 
the  rash  of  measles,  and  when  the  differentiation  between  scarlet 
fever  and  measles  is  rendered  obscure  by  an  atypical  rash,  we  must 
bear  in  mind  what  a  wide  difference  there  is  in  the  other  symptoms 


634  THE  SPECIFIC  INFECTIOUS  DISEASES 

of  these  two  afPections,  and  this  will  usually  permit  us  to  make  a 
definite  differential  diagnosis.  The  onset  of  scarlet  fever  is  more 
severe,  the  fever  higher,  the  attacks  of  vomiting  more  frequent, 
and  the  rash  appears  earlier  than  in  measles;  while  photophobia, 
coryza,  cough,  and  hoarseness  are  peculiar  to  rubeola.  Sore  throat, 
strawberry  tongue,  and  cervical  glandular  enlargement  are  character- 
istic of  scarlatina,  and  the  Koplik's  spots  of  measles  are  absent.  . 

Ruhella. — The  eruption  of  German  measles  resembles  that  of 
scarlet  fever  more  closely  than  does  that  of  rubeola;  but,  as  a  rule, 
it  is  not  followed  by  desquamation,  and  there  are  no  severe  throat 
symptom.s.  The  constitutional  disturbances  are  much  milder  in 
rubella  than  in  scarlatina,  and  the  course  of  the  disease  is  shorter. 
In  German  measles  the  posterior  cervical  glands  are  enlarged. 

Drug  Rashes. — The  various  drug  rashes  may  be  diagnosed  from 
the  history  and  other  untoward  symptoms  which  appear  with  the 
rash.  In  acute  exfoliative  dermatitis  there  are  no  throat  symptoms 
and  the  tongue  lacks  the  appearance  so  characteristic  of  scarlet  fever. 

Complications. — Acute  nephritis  is  the  most  common  complication 
of  scarlet  fever,  and  usually  occurs  in  the  second,  third,  or  fourth 
week,  after  desquamation  is  more  or  less  complete.  A  slight  albumin- 
uria often  appears  at  the  height  of  the  fever,  but  does  not  signify 
acute  nephritis,  or  predispose  to  it,  although  the  cells  lining  the 
tubules  are  at  this  time  in  a  state  of  cloudy  swelling. 

The  nephritis  of  scarlet  fever  is  in  all  probability  caused  by  the 
specific  toxin  or  bacillus,  and  the  frequency  with  which  this  inflam- 
mation of  the  kidneys  occurs  in  scarlet  fever  is  to  be  attributed  to 
the  increased  work  thrown  upon  the  kidneys  because  of  the  impair- 
ment of  the  function  of  the  skin.  Acute  parenchymatous  nephritis 
is  the  most  common  form  of  the  kidney  affection,  but  intersitial 
nephritis  also  occurs.  The  majority  of  cases  progress  favorably, 
although  the  disease  may  appear  in  all  degreees  of  severity. 

Throat. — Scarlatinal  angina  is  a  very  common  complication,  and 
is  the  result  of  streptococcic  infection  of  the  throat.  It  differs  from 
diphtheria  in  that  it  rarely  spreads  to  the  larynx  or  causes  paralysis. 
True  diphtheria,  however,  is  occasionally  associated  with  scarlet  fever. 

If  the  non-diphtheritic  membrane  seen  in  scarlet  fever  shows  a 
tendency  to  spread,  it  may  prove  a  source  of  danger  by  extending 
into  the  nasopharynx  and  along  the  Eustachian  tube  to  the  middle 
ear.  Swallowing  may  become  both  difficult  and  painful;  irritating 
discharges  may  exude  from  the  nose;  the  breath  is  foul.  Ludwig's 
angina  may  appear.  Gangrene  of  the  tonsils  and  ulceration  may 
occur,  and  sometimes  involve  the  uvula,  fauces,  and  pharynx. 

In  severe  cases  the  cellular  tissues  of  the  neck  become  infiltrated 
and  slough  or  suppurate,  occasionally  causing  hemorrhages  from  the 
tonsils  or  vessels  of  the  neck,  and  thrombosis  of  the  jugular  vein. 
Death  may  ensue  from  hemorrhage  or  from  septicemia.  In  these 
cases  the  constitutional  symptoms  are  all  aggravated,  while  asthenia, 
cachexia,  and,  eventually,  collapse  precede  the  fatal  termination. 


SCARLET  FEVER  '    635 

In  the  rare  cases  in  which  the  larynx  is  involved  edema  of  the  glottis 
occurs,  and,  if  there  be  suppuration  in  the  throat,  the  pus  may  pass 
into  the  mediastinum  and  neighboring  structures,  setting  up  puru- 
lent pleurisy  and  pericarditis,  with  symptoms  of  embolism,  throm- 
bosis, or  septicemia,  and  usually  terminates  fatally. 

Ears. — The  ears  become  involved  in  scarlet  fever  by  extension 
from  the  throat  along  the  Eustachian  tubes.  This  occurs  more 
frequently  in  younger  children,  and  causes  the  usual  symptoms  of 
otitis  media,  such  as  earache,  restlessness,  and  a  rise  in  temperature, 
with  congestion  and  bulging  of  the  drum  membrane,  which,  in  the 
majority  of  cases,  eventuates  in  perforation  of  the  tympanum. 
When  the  drum  membrane  is  resistant,  and  rupture  is  delayed, 
mastoiditis  and  meningitis  may  supervene.  It  is  estimated  that  10 
per  cent,  of  chronic  deafness  is  due  to  scarlatinal  otitis,  w^hich  in  very 
young  children  may  produce  deaf-mutism. 

Lymjih  Nodes. — The  submaxillary  glands  are  always  enlarged  in 
scarlet  fever,  and  when  the  throat  symptoms  are  severe  there  is  con- 
siderable swelling  of  these  and  of  the  cervical  lymph  nodes.  Suppura- 
tion may  take  place,  or  the  inflammation  may  not  proceed  beyond  the 
acute  inflammatory  stage. 

Joints. — Scarlatinal  arthritis  mi  ay  appear  early  in  the  disease, 
and  in  these  cases  the  inflammation  is  migratory,  affecting  the  same 
joints  which  are  commonly  involved  in  adults  who  have  acute  inflam- 
matory rheumatism.  These  cases  simulate  acute  inflammatory 
rheumatism,  and  respond  to  treatment  with  the  salicylates,  but  are 
regarded  as  scarlatinal.  Occasionally  a  less  transient  arthritis,  which 
is  septic  in  origin,  appears  late  in  the  course  of  scarlet  fever,  and 
involves  one  or  several  joints. 

Nervous  System. — Among  the  occasional  complications  of  scarlet 
fever  are  convulsions  and  meningitis.  Chorea  and  hemiplegia  are 
quite  rare,  and  but  few"  cases  of  paralysis  have  been  reported  as 
following  scarlatina. 

Heart. — ^Transient  murmurs  are  not  infrequently  heard  during 
the  course  of  scarlet  fever,  and  of  these  the  mitral  systolic  is  the 
most  common.  There  is  often  extreme  irregularity  of  the  heart's 
action,  and  a  "hniit  de  galojj"  is  occasionally  heard.  Transient  mur- 
murs are  thought  to  be  due  to  a  loss  of  cardiac  muscular  tone,  and 
consequent  imperfect  closure  of  the  heart  valve. 

Acute  dilatation  of  the  heart  may  take  place  during  the  height 
of  the  fever,  and  endocarditis  and  pericarditis  occasionally  appear. 
Cases  of  malignant  endocarditis  are  less  numerous  than  would  be 
expected  from  the  virulence  and  wide-spread  action  of  the  infecting 
organism,  and  it  is  evident  that  the  heart  is  affected  more  by  scarla- 
tinal toxins  than  by  the  germ  which  produces  the  disease. 

Lungs. — Pneumonia  is  one  of  the  early  complications  of  scarlet 
fever,  and  may  be  either  lobular  or  lobar  in  type;  but  pulmonary 
complications  are  not  as  frequent  or  as  severe  as  in  measles.  A  septic 
or  aspiration  pneumonia  (bronchopneumonia)  is  liable  to  occur  in  the 
severe  septic  anginal  cases. 


636 


THE  SPECIFIC  INFECTIOUS  DISEASES 


Miscellaneous. — ^Among  the  various  other  comphcations  of  scarlet 
fever  may  be  mentioned  the  following:  Gastro-intestinal  disturbances 
in  which  vomiting  is  a  marked  feature,  hyperpyrexia,  osteomyelitis, 
ophthalmia,  and  other  infectious  diseases  of  which  diphtheria,  measles, 
and  varicella  are  the  most  common. 

Prognosis. — The  prognosis  in  scarlet  fever  depends  upon  the  char- 
acter of  the  epidemic,  the  prevalent  type  of  the  disease,  the  age 
of  the  patient,  and  the  presence  or  absence  of  complications.  When 
cases  are  isolated  and  skilfully  treated  from  the  onset  of  the  disease, 
the  prognosis  is  usually  favorable  and  the  mortality  is  not  high  except 
in  very  young  children.  In  severe  cases  the  prognosis  should  always 
be  guarded,  and  persistent  albuminuria,  profuse  diarrhea,  and  marked 
angina  or  otitis  are  danger  signals. 

The  hemorrhagic  form  is  always  serious,  affections  of  the  endo- 
cardium or  pleura  may  prove  fatal,  and  nearly  all  of  the  malignant 
septic  cases  die.  A  child  with  scarlet  fever  should  not  be  pronounced 
out  of  danger  until  after  the  fourth  week  has  passed  with  no  compli- 
cations. 


Number  of 

Deaths  in  Philadelphia — Scarlet  Fever. 

Age  period. 

1911. 

1912. 

1913. 

1914. 

191.5. 

Total 

mortality 

for  five  years. 

Per  cent,  of 
mortality  com- 
pared with 
mortality  at 
all  ages. 

Under  1  year  . 

7 

3 

3 

4 

1 

18 

3.0 

1  to    2  year3   . 

19 

8 

13 

no  data 

no  data 

8.8 

2  to    5      "       . 

85 

55 

71 

60 

8 

279 

45.0 

5  to  10      " 

39 

34 

54 

34 

4 

185 

27.1 

10  to  15      "       . 

7 

6 

9 

5 

3 

30 

5.0 

15  to  20      "       . 

7 

1 

2 

4 

2 

16 

2.6 

All  ages 

179 

113 

162 

129 

25 

608 

Treatment. — Prophylaxis  is  an  exceedingly  important  part  of  the 
treatment  in  scarlet  fever,  the  organism  and  infectious  principle  of 
the  disease  being  so  difficult  to  exterminate.  The  patient  should 
be  isolated  as  soon  as  the  diagnosis  is  m.ade,  and  strict  c^uarantine 
maintained. 

If  several  children  in  the  same  house  are  affected,  each  child  should 
be  assigned  to  a  separate  room,  or  reinfection  may  occur.  The  sick- 
room should  be  one  that  can  be  isolated  completely,  and  every  port- 
able object  should  be  removed  from  the  room  except  those  absolutely 
needed.  All  the  children  in  the  family  should  be  kept  from  school, 
and  contacts  who  have  angina  should  not  be  allowed  to  mingle  with 
well  persons. 

Sheets  soaked  in  a  1  to  2000  bichloride  solution  should  be  hung  in 
front  of  the  door  of  the  sick-room,  and  all  bed  linen  and  clothing  used 
by  the  patient  should  be  soaked  in  a  1  to  5000  bichloride  solution  before 
being  sent  to  the  laundry,  then  boiled  and  sun-dried.  Clothing  of  the 
nurse  or  attendant  should  be  washable,  and  she  should  wear  a  close- 
fitting  cap  to  prevent  the  hair  from  becoming  contaminated.     She 


SCARLET  FEVER  637 

should  also  spray  her  throat  twice  daily  with  1  to  5  glycothymoline 
solution,  liquor  alkalinus  antisepticus,  or  with  hydrogen  peroxide. 

The  attending  physician  should  never  enter  the  sick-room  without 
removing  his  coat  and  vest  and  donning  a  linen  gown  and  close-fitting 
cap.  At  the  termination  of  his  visit  he  should  remove  the  robe  and 
cap  just  outside  the  sick-room.,  disinfect  his  hands  and  face,  and  go 
home  to  change  and  air  his  clothes  before  visiting  other  patients. 

The  sick-room  should  be  thoroughly  disinfected  after  the  patient 
is  convalescent  before  it  can  again  be  used,  and  the  mattress  had 
better  be  burned.  During  occupancy  as  much  sunlight  as  possible 
should  be  allowed  to  enter  the  room,  and  it  should  be  kept  at  an  even 
temperature  of  70°  F.,  and  be  well  ventilated;  an  open  fireplace  is  of 
great  advantage. 

While  the  fever  is  high  milk  is  the  best  food,  and  after  the  tempera- 
ture declines  a  bland  soft  diet  may  be  allowed.  The  child  should 
drink  plenty  of  water,  and  when  the  fever  runs  high  (103°  F.  and 
above)  tepid  or  cool  spongings  will  afford  relief. 

The  skin  should  be  anointed  with  a  boric  acid  ointment  or  with 
cocoa  butter  to  lessen  the  tension;  if  the  itching  is  severe,  with  a 

1  per  cent,  phenol  ointment.  Cold  cream,  sweet  oil,  5  per  cent, 
ichthyol  ointment,  and  oil  of  eucalyptus  have  all  been  used  to  relieve 

,the  skin  irritation.  The  scales  should  be  removed  by  daily  baths  of 
tepid  water  and  green  soap. 

The  throat  sym.ptom.s  require  treatment  according  to  their  severity; 
when  mild  no  local  applications  are  necessary,  although  saline  or 
boric  acid  washes  and  sprays  may  be  used  as  prophylactic  measures. 
If  an  exudate  is  present  in  the  throat,  25  or  50  per  cent,  hydrogen 
peroxide  solution,  or  1  to  5000  bichloride,  op  1  to  60  carbolic  acid 
solution  may  be  used  locally  as  a  spray.  If  the  nose  is  involved,  it 
should  be  gently  irrigated  with  a  normal  saline  solution. 

Cold  applications  externally,  such  as  ice-bags  to  the  throat,  aft'ord 
great  relief  and  are  very  soothing.  Careful  attention  to  the  throat 
tends  to  prevent  otitis;  but,  if  it  occurs,  the  pain  can  often  be  relieved 
by  gently  syringing  the  ear  with  warm,  normal  saline  solution.  The 
ears  should  be  inspected  daily,  and  if  bulging  of  the  tym.panic  mem- 
brane is  observed  m.yringotom.y  should  be  performed  im.mediately. 

Nephritis  is  best  guarded  against  by  prolonged  rest  in  bed  and 
daily  urinary  examinations.  The  actual  treatment  of  a  complicating 
nephritis  consists  in  restriction  of  the  diet  to  milk  and  enforced  rest 
in  bed.    In  addition,  the  bowels  should  be  kept  opened  freely,  1  or 

2  grains  of  calomel  in  divided  doses  being  given  at  the  onset,  and 
followed  by  magnesium  citrate,  2  to  6  dram.s,  or  magnesium, 
sulphate,  1  to  2  drams.  Alkaline  diuretics  are  also  indicated 
and  5  to  20  grains  of  potassium  citrate  may  be  given  every  tlii-ee 
hours. 

Hot  packs  tend  to  make  the  skin  more  active,  thus  relieving  the 
overburdened  kidneys,  and  may  prevent  uremia  and  convulsions. 
If  convulsions  or  uremic  symptoms  develop,  the  child  should  be  put 


638  THE  SPECIFIC  INFECTIOUS  DISEASES 

in  a  hot  bath.  If  this  has  no  effect,  a  hypodermic  injection  of  ^V 
to  2-V  of  a  grain  of  morphine,  and  ^-q  of  atropine  may  be  given. 
Lumbar  puncture  often  gives  excellent  results  in  these  cases. 

If  a  diphtheritic-looking  exudate  appears  during  the  first  week, 
it  is  usually  a  safe  plan  to  administer  2000  to  5000  units  of  antitoxin, 
which  can  be  repeated  if  it  proves  to  be  true  diphtheria.  In  adynamic 
cases  20  to  40  drops  of  brandy  may  be  given  every  three  or  four  hours, 
and  if  the  heart  is  weak  ^-q-Vf  to  xff  of  ^  grain  of  strychnine  with  1 
to  3  drops  of  digitalis  may  be  administered  at  like  intervals. 

Malignant  cases  require  continuous  and  powerful  stimulation  with 
whisky,  15  to  40  drops,  caffeine,  gr.  j  to  ^,  and  camphorated  oil,  10 
to  15  drops  hypodermically  every  two  to  four  hours,  according  to 
indications. 

Cerebral  irritation  may  call  for  the  administration  of  either 
sodium  bromide,  5  to  10  grains,  Dover's  powder,  |  to  1  grain, 
or  codein  sulphate,  gV  to  yg-  of  a  grain,  three  times  a  day. 
Vomiting  and  diarrhea,  if  troublesom.e,  may  be  aHayed  by  giving 
bismuth  subnitrate,  10  to  20  grains,  with  paregoric,  5  to  15  drops, 
or  Dover's  powder,  |  to  1  grain,  three  times  a  day.  For  digestive 
disturbances  in  young  children,  sm.all  doses  of  calom.el  and  bismuth 
are  very  efficacious. 

When  the  joints  are  involved  they  should  be  immobilized,  methyl, 
salicylate  applied,  and  the  joint  then  warmly  wrapped  in  cotton- 
w^ool.  Sodium  salicylate,  5  to  10  grains,  combined  with  twice 
this  amount  of  sodium  bicarbonate,  should  be  given  three  or  four 
times  daily.  If  suppuration  takes  place  in  the  joint,  surgical  inter- 
vention is  necessary! 

The  constitutional  treatment  of  scarlet  fever  is  largely  symptomatic, 
since  there  are  no  known  specific  drugs.^  If  the  rash  does  not  appear 
within  the  usual  time,  warm  baths,  a  mustard  bath,  foot-baths,  or 
a  hot  pack  should  be  given,  also  hot  drinks  containing  10  grains  of 
citrate  of  potassium,  or  5  to  10  drops  of  sweet  spirits  of  nitre.  . 
Constipation  must  be  prevented.  Antipyretics  are  contra-indicated; 
but  ice-bags  to  the  head  are  often  a  great  comfort  when  the  fever  is 
high. 

Serum  Therapy. — Good  results  have  recently  been  reported  from 
the  use  of  antistreptococcic  serum  and  from  serum  obtained  from  con- 
valescents. In  those  cases  where  the  effect  is  favorable,  one  may 
note  after  an  injection  a  drop  in  the  temperature,  a  decrease  in  the 
pulse  rate,  and  improvement  in  the  force  and  rhythm  of  the  heart. 
From  20  to  80  c.c.  of  antistreptococcic  serum  a  day  should  be  given 
in  all  malignant  and  complicated  cases,  as  long  as  the  dangerous 
symptoms  continue. 

Convalescence. — During  convalescence  the  child  should  be  on  a 
full,  nourishing,  and  easily  digested  diet.  A  hot  soapsuds  bath  should 
be  given  every  second  day,  and  this  followed  by  an  inunction  of  olive 
or  sweet  oil.  After  desquamation,  if  there  is  no  nephritis,  the  child 
may  play  about  out  of  doors;  but  should  not  be  allowed  to  come  in 


VARICELLA  ,  639 

contact  with  other  children  for  six  weeks  after  the  onset  of  the  disease. 
If  there  is  anemia,  Basham's  mixture,  10  to  20  drops,  or  tincture  of 
ferric  chloride,  2  to  5  drops,  may  be  given  three  times  a  day 
after  meals.  The  syrup  of  ferric  iodide,  10  to  20  drops,  and  cod-liver 
oil,  5  to  1  dram,  are  also  valuable  tonics  at  this  time.  If  possible, 
these  children  should  be  sent  away  to  the  shore  or  mountains  to 
recuperate. 

VARICELLA    (CHICKEN-POX). 

Varicella  is  an  acute  contagious  disease,  characterized  by  an  erup- 
tion of  vesicles  on  the  skin  together  with  mild  constitutional  symp- 
toms. In  the  vast  majority  of  cases,  one  attack  of  chicken-pox 
protects  the  individual  against  th^  disease  for  life,  and  because  nearly 
everyone  contracts  it  during  childhood  it  is  rarely  seen  in  adults. 
Varicella  is  quite  separate  and  distinct  from  vaccinia  or  variola,  and 
an  attack  of  chicken-pox  affords  no  protection  against  these  diseases. 

Furthermore,  inoculation  with  the  virus  of  varicella,  when  success- 
ful, will  produce  varicella,  and  no  other  disease;  likewise,  variola 
inoculation  w^ill  always  produce  smallpox.  Vaccinia,  varicella,  and 
variola  may  occur  successively  in  the  same  person  within  a  relatively 
short  space  of  time. 

Etiology. — Chicken-pox  occurs  both  in  endemic  and  epidemic 
form,  though  sporadic  cases  are  frequently  seen.  No  specific  micro- 
organism has  as  yet  been  isolated.  It  is  usually  contracted  by  direct 
contact  or  conveyed  by  a  third  person,  and  may  also  be  air-borne 
for  a  short  distance.  It  is  chiefly  a  disease  of  childhood,  occurring 
in  the  vast  majority  of  instances  between  the  second  and  sixth  years; 
but  no  age  is  absolutely  exempt,  as  it  is  occasionally  observed  in 
very  young  infants  as  well  as  in  adults.  It  is  highly .  contagious, 
in  this  respect  being  somewhat  like  measles.  Most  cases  are  observed 
during  the  autumn  months.  The  period  of  incubation  is  usually 
between  two  and  three  weeks,  but  it  may  be  a  little  longer  or  a  little 
shorter. 

Symptoms. — In  the  majority  of  cases  there  are  no  prodromes, 
but  there  may  sometimes  be  a  feeling  of  malaise  during  the  later 
stages  of  the  incubation  period,  while  a  day  or  so  before  the  eruption 
appears  there  may  be  slight  fever,  headache,  restlessness,  and  mus- 
cular pain.  In  exceptional  cases  a  prodromal  scarlatiniform  rash 
has  been  seen  upon  the  trunk. 

The  onset  occurs  with  fever,  often  with  chills,  and  there  may  be 
angina,  conjunctivitis,  and  even  convulsions  in  severe  cases.  Occasion- 
ally there  is  vomiting,  with  pains  in  the  back  and  legs.  Often  the 
first  symptom  noted  is  the  eruption,  which  usually  appears  first 
either  on  the  face  or  the  trunk,  but  may  occur  without  any  character- 
istic grouping  upon  any  part  of  the  body.  In  some  instances  exan- 
themata may  be  seen  upon  the  mucous  membranes  of  the  mouth, 
palate,  tongue,  and  throat,  and  exceptionally  on  the  nasal  and  vulvar 
mucous  membranes. 


640  THE  SPECIFIC  INFECTIOUS  DISEASES 

As  a  rule  the  eruption  is  scant  upon  tli^  extremities,  the  hands  and 
feet  being  rarely  affected.  It  appears  in  the  form  of  small,  red, 
elevated  papules  which,  within  a  few  hours,  are  transformed  into 
vesicles  containing  a  clear  fluid.  The  papules  generally  appear  in 
crops,  soon  followed  by  succeeding  crops  of  new  ones  on  the  same  or 
other  parts  of  the  body.  The  first  crop  of  papules  generally  dries  up 
before  the  appearance  of  the  next  one.  In  consequence,  all  stages  of 
the  eruption  may  be  seen  at  one  time  upon  the  same  part  of  the  body, 
this  being  a  diagnostic  sign  of  great  value. 

There  is  usually  no  umbilication  of  the  vesicles.  In  the  majority 
of  cases  they  are  flat,  and  vary  in  diameter  from  one-eighth  to  one- 
fourth  of  an  inch.  Seldom  is  the  skin  about  the  vesicle  reddened  or 
infiltrated.  After  the  first  or  second  day  the  fluid  in  the  vesicles 
becomes  purulent  and,  within  twenty-four  to  forty-eight  hours  later, 
the  vesicles  show  signs  of  drying  up,  this  beginning  in  the  centre, 
and  producing  a  slight  depression  which  somewhat  resembles  umbili- 
cation. 

Crusts  form  which,  according  to  the  degree  of  skin  involvement, 
fall  off  any  time  between  the  seventh  and  twenty-first  days.  Only 
after  the  most  severe  cases,  and  when  secondary  infection  has  taken 
place  from  scratching,  are  any  marks  left,  pitting  depending  upon 
whether  or  not  there  has  been  involvement  of  the  true  skin.  Even 
in  such  an  event,  the  pits  are  few,  and  most  apt  to  be  on  the  face. 
A  diagnostic  point  of  value  is  the  fact  that  pocks  are  almost  invariably 
seen  on  the  scalp,  which  is  rarely  the  case  in  smallpox. 

Frequently  the  rash  becomes  so  modified  that  it  assumes  a  peculiar 
appearance.  Necrosis  may  occur  about  the  pock,  thus  producing  a 
condition  known  as  varicella  gangrenosa.  This  type  of  eruption  is 
most  commonly  seen  in  institutions,  where  the  children  are  apt  to 
be  puny  and  poorly  nourished,  and  in  these  cases  the  disease  may 
be  fatal.  It  is  believed  to  be  due  to  a  mixed  infection.  Or,  the  vesicles 
may  become  exceedingly  large,  and  resemble  bullae,  having  all  the 
appearance  of  pemphigus,  this  condition  being  known  sisvariceUabnUosa. 

The  constitutional  symptoms  in  varicella  are  usually  mild.  The 
fever  rises  to  101°  or  102°  F.  on  the  appearance  of  the  eruption,  and 
does  not  usually  decline  until  the  second  or  third  day.  It  is  slight 
except  in  severe  cases,  when  it  may  rise  to  104°  or  105°  F.,  and  last 
four  or  five  days.  Usually  it  returns  to  normal  as  the  rash  gradually 
disappears,  but  may  again  rise  with  the  appearance  of  a  fresh  crop 
of  vesicles.  Only  when  the  skin  lesions  of  varicella  become  second- 
arily infected  does  the  temperature  remain  elevated  for  more  than 
a  few  days. 

Hemorrhagic  varicella  is  exceedingly  rare;  it  is  usually  accompanied 
by  bleeding  from  the  mucous  membranes. 

Diagnosis. — This  is  obvious  if  the  case  has  been  seen  from  the  onset. 
The  marked  predominance  of  the  rash  on  the  trunk,  the  appearance 
of  the  eruption  in  crops  of  papules  which  change  into  vesicles  and 
crusts,  and  the  slight  umbilication  resulting  from  the  drying  of  the 


VARICELLA  641 

vesicles,  ought  to  render  the  diagnosis  easy.  In  the  absence  of  an 
epidemic  of  smallpox,  the  differentiation  between  smallpox  and 
chicken-pox  is  not  difficult;  but  when  there  is  an  outbreak  of  variola 
mild  cases  of  smallpox  may  closely  simulate  varicella,  and  a  severe 
attack  of  chicken-pox  closely  resemble  variola. 

It  should  always  be  borne  in  mind  that  in  varicella  the  temperature 
is  lower  and  the  duration  of  the  fever  shorter  than  in  even  very  mild 
smallpox.  The  history  of  a  recent  successful  vaccination  renders 
the  possibility  of  smallpox  in  that  particular  individual  most  unlikely. 
The  superficial  character  of  the  pocks  and  their  appearance  in 
successive  crops,  the  absence  of  infiltration  and  true  umbilication, 
together  with  the  mildness  of  the  constitutional  symptoms,  are 
important  factors  in  eliminating  smallpox. 

Impetigo  may  be  simulated  by  the  dried  crusts  of  chicken-pox;  but 
in  impetigo  there  are  no  constitutional  symptoms,  no  lesions  upon 
the  mucous  membranes,  and  the  eruption  persists  for  a  longer  period 
than  do  the  skin  manifestations  of  varicella.  If  the  suspected  case 
be  chicken-pox,  it  can  probably  be  traced  to  other  cases,  and  it  will 
run  a  shorter  course  than  impetigo,  the  lesions  disappearing  without 
treatment. 

Complications. — Complications  and  sequela?  are  seldom  observed, 
but  occasionally  pneumonia,  pleurisy,  bronchitis,  laryngeal  stenosis, 
otitis  media,  synovitis,  or  arthritis  may  be  encountered.  Polioen- 
cephalitis is  a  very  rare  complication  which  causes  stupor  or  extreme 
restlessness  and  paresis  of  the  extremities.  A  fatal  termination'  is 
rare,  even  in  these  cases. 

Where  there  is  suppuration  about  the  pocks  erysipelas  may  de- 
velop, and  often  proves  fatal.  Nephritis,  though  not  a  frequent 
complication,  may  occur  either  at  the  height  of  the  disease  or  during 
convalescence.  The  urine  passed  by  children  who  have  chicken-pox 
often  shows  a  trace  of  albumin. 

Other  contagious  diseases,  particularly  scarlet  fever,  may  complicate 
varicella,  especially  in  institutions;  occasionally  we  may  see  simple 
or  suppurative  adenitis. 

Prognosis. — Simple  uncomplicated  cases  almost  invariably  recover, 
for  varicella  is  the  mildest  of  all  the  acute  contagious  diseases  with 
the  possible  exception  of  rubeola.  Even  in  complicated  cases  death 
is  uncommon,  and  a  fatal  outcome  is  never  to  be  feared  except  when 
erysipelas,  sepsis,  or  varicella  gangrenosa  occurs  in  weak,  debilitated 
children. 

Treatm.ent. — Children  suffering  from  the  disease  should  be  isolated 
from  other  children  for  a  period  of  at  least  two  weeks,  or  until  the 
crusts  have  completely  disappeared,  as  it  is  while  the  vesicles  are 
present  that  the  contagion  is  at  its  height.  If  there  is  elevation  of 
tejiiperature,  rest  in  bed  should  be  enforced,  and  the  diet  restricted 
to  liquids  while  the  symptoms  are  acute.  An  initial  purge  of  castor 
oil,  1  to  4  drams  according  to  age,  or  2  to  6  drams  of  citrate  of 
magnesia,  is  also  advisable. 
41 


642  THE  SPECIFIC  INFECTIOUS  DISEASES 

In  the  majority  of  cases  the  constitutional  symptoms  are  so  mild 
as  to  require  little  or  no  treatment.  The  itching  may  be  allayed  by 
the  application  of  a  2  to  3  per  cent,  solution  of  carbolic  acid, 
or  a  saturated  solution  of  sodium  bicarbonate,  or  by  the  use  of  tincture 
of  iodine  or  carbolized  vaseline  (2  to  3  per  cent.).  Warm  baths 
will  also  relieve  the  itching,  as  will  the  application  of  the  following 
ointment: 

I^ — Acidi  salicylici, 

Thymolis ;      .      .   '  .      .      .      .   aa  gr.  xx 

Ung.  zinci  oxidi 5ij — M. 

Sig. — Apply  locally  night  and  morning. 

Cases  in  which  the  rash  is  abundant,  particularly  upon  the  face, 
should  be  prevented  from  scratching  the  pustules  by  keeping  the 
finger-nails  closely  trimmed  and  by  applying  splints  to  the  elbows, 
if  necessary,  so  that  the  affected  parts  cannot  be  reached;  also  by 
enclosing  the  hands  in  mittens  tied  securely  at  the  wrists. 

If  the  vesicles  are  punctured  as  they  become  pustular,  and  a 
saturated  solution  of  boric  acid  is  applied,  secondary  infection  and 
resultant  pockmg  may  be  averted.  A  mild  ointment,  such  as  vaseline, 
may  subsequently  be  applied  to  the  crusts. 

MEASLES  (MOKBILLI—RUBEOLA). 

Measles  is  an  acute  contagious  disease,  occurring  in  epidemics,  and 
characterized  by  an  early  eruption  on  the  buccal  mucous  membrane 
and  catarrrhal  symptoms,  later  by  a  rash  which  covers  the  entire 
body,  and  by  the  development  of  bronchitis. 

Etiology. — ^The  specific  microorganism  that  causes  measles  is  as 
yet  unknown,  but  its  viability  outside  the  human  body  is  not  great. 
The  disease  can  be  reproduced  in  man  by  subcutaneous  inoculation 
with  the  blood  taken  from  a  measles  patient  during  the  twenty-four 
hours  before  the  eruption,  and  thirty  hours  after  the  first  appear- 
ance of  the  eruption — in  all  fifty-four  hours. 

Accordmg  to  Anderson  and  Goldberger,  the  virus  can  pass  through 
a  Berkefeld  filter,  and  may  resist  desiccation  for  twenty-five  and 
one-half  hours.  Its  infectivitj^  is  destroyed  by  heating  at  55 °C.  for 
fifteen  minutes.  It  resists  freezing  for  twenty-five  hours,  and  possibly 
retains  some  infectivity  after  keeping  twenty-foiir  hours  at  15°  C.  A 
monkey  which  has  acquired  the  disease  by  contact  or  inoculation 
remains  immune. 

The  virus  exists  in  the  blood  and  in  the  secretions  of  the  nose, 
eyes,  mouth,  and  bronchi  of  infected  individuals,  especially  during 
the  height  of  the  disease,  rapidly  lessens  as  the  rash  fades,  and 
disappears  entirely  with  the  disappearance  of  the  rash.  The  disease 
is  only  slightly,  if  at  all,  contagious  after  the  fading  of  the  rash.  It 
has  been  produced  by  inoculation  with  the  blood,  and  the  discharge 
from  the  eyes,  nose,  mouth,  pharynx,  bronchi,  and  vesicles  of  a  patient 


MEASLES  643 

who  has  measles,  but  the  contagion  does  not  exist  m  the  scales.  No 
growth  in  any  way  connected  etiologically  with  the  disease  can  be 
obtained  from  the  blood  of  a  measles  patient. 

Measles  is  easily  spread  from  one  child  to  another.  A  very  short 
exposure  is  sufficient  for  contracting  it,  close  contact  not  being  neces- 
sary. Infants  under  six  months  are  less  susceptible  than  older  chil- 
dren, which  is  also  true  of  rubella,  and,  in  a  less  degree,  of  scarlet 
fever,  but  all  other  children,  if  exposed,  usually  contract  it.  The 
non-susceptibility  of  the  newborn  to  measles  is  shown  by  the  follow- 
ing case  which  came  under  my  notice: 

Mrs.  S.  was  seen  on  the  morning  of  February  28,  with  coryza,  a 
cough,  a  temperature  of  102.4°  F.  The  rash  of  measles  covered  her 
face  and  upper  neck,  and  there  were  also  a  few  isolated  spots  on  her 
body.  The  following  morning,  after  a  normal  labor  at  the  end  of 
the  full  period  of  uterogestation,  a  male  infant,  presenting  absolutely 
nothing  abnormal,  w^as  born.  By  this  time  the  rash  had  spread  over 
the  entire  body  of  the  mother.  The  baby  was  free  from  rash,  had  a 
normal  temperature,  and  presented  nothing  unusual.  It  was  at  no 
time  isolated  from  its  mother,  was  nursed  regularly  every  two  hours, 
and  treated  exactly  as  if  it  were  not  exposed  to  the  contagion  of 
measles.  With  the  exception  of  a  severe  laryngitis,  the  mother  made 
an  uninterrupted  recovery.  When  the  infant  was  nine  days  old, 
another  child  of  the  family,  a  boy  aged  eighteen  months,  developed  a 
typical  attack  of  measles.  Up  to  the  age  of  six  weeks,  the  baby 
had  shown  no  symptoms  of  the  affection. 

The  disease  may  be  acquired  in  utero,  the  mother  having  the 
disease,  and  the  child  show  the  typical  signs  of  measles  at  birth  or 
within  a  few  days  after  birth.  A.  Bartsch  reports  a  case  where  the 
infant  was  born  on  the  day  when  the  rash  first  appeared  on  the 
mother.  When  the  baby  was  three  days  old,  it  presented  the  rash, 
temperature,  and,  indeed,  a  perfect  clinical  picture  of  measles.  The 
child  recovered  without  any  complications. 

Another  illustration  of  measles  in  early  infancy  is  shown  by  the 
following  case  which  occurred  in  my  service  in  the  Philadelphia 
Hospital : 

A  baby  was  born  December  4,  1912.  The  mother  showed  the  rash 
of  measles  January  6,  and  it  appeared  on  the  baby  on  January  17. 
On  January  20,  the  baby's  temperature  w^as  normal,  and  the  rash 
had  faded.    The  rash  in  this  case  appeared  forty -four  days  after  birth. 

Epidemics  are  more  severe  in  the  winter  and  spring.  The  period 
of  incubation  is  from  nine  to  seventeen  days,  usually  about  fourteen 
days.  The  catarrhal  symptoms  generally  appear  eleven  days,  and  the 
rash  fourteen  days  after  exposure  to  the  disease.  Measles  occurs 
in  all  parts  of   the  world.     Boys  and   girls  are  equally  susceptible. 

About  60  per  cent,  of  all  cases  occiu"  under  five  years  of  age,  and 
almost  30  per  cent,  of  the  remaining  cases  in  the  next  five  years  of 
life.  If,  however,  measles  is  brought  to  a  community  which  has  never 
previously  been  infected,  people  of  all  ages  are  attacked  by  the  disease, 


644  THE  SPECIFIC  INFECTIOUS  DISEASES 

the  old  as  well  as  the  young.  Many  cases  happen  in  young  men  and 
women  who  come  to  cities  from  isolated  rural  districts  where  they 
have  never  been  exposed  to  the  infection.  Taking  up  their  residence 
in  a  community  where  measles  is  always  present  they  contract  it. 
In  the  adult  it  is  rare  simply  because  almost  everyone  has  the  disease 
in  childhood.  It  is,  however,  more  common  in  young  adult  life  than 
is  scarlet  fever. 

A  third  person  may  convey  it,  but  only  for  a  short  time  or  distance, 
or  it  may  be  carried  on  the  clothes,  or  on  fomites  which  have  been 
used  by  the  patient.  The  disease  is  often  contracted  by  large  num- 
bers of  children  from  a  single  case  occurring  in  a  school  or  at  some 
entertainment  given  for  children.  It  is  contagious  from  the  earliest 
catarrhal  symptoms,  and  almost  all  who  are  exposed  contract  the 
disease.  A  second  attack  is  rare,  but  may  occur,  and  three  attacks 
in  one  individual  have  been  reported. 

Measles  is  endemic  in  all  large  cities,  but  most  of  the  cases  occur 
in  epidemics  which  recur  at  irregular  intervals  of  two,  three,  or  five 
years.  As  almost  all  children  of  school  age  are  exposed  and  contract 
the  disease,  the  epidemic  disappears  only  when  all  of  the  susceptible 
children  who  have  been  exposed  have  contracted  measles,  and  it 
reappears  when  there  is  a  new  enrolment  of  pupils.  As  school 
epidemics  commonly  spread  the  disease,  a  single  case  calls  for  prompt 
disinfection.  It  is  especially  contagious  from  the  first  symptom  of 
the  catarrhal  stage,  and,  to  a  less  degree,  during  the  later  or  desqua- 
mating period.  The  infection  does  not  cling  or  last  after  convalescence 
and  at  the  end  of  three  weeks  the  patient  and  the  sick-room  are  free 
from  it. 

Pathological  Anatomy. — The  main  lesions  are  in  the  skin  and  mucous 
membranes.  The  skin  shows  a  superficial  inflammation,  with  conges- 
tion* and  swelling  which  involve  the  glandular  structure  and  the 
papillae.  There  is  invariably  a  catarrhal  inflammation  of  the  eyes, 
nose,  mouth,  pharynx,  larynx,  trachea,  and  larger  bronchi.  The 
cervical  and  bronchial  glands  are  swollen,  there  is  swelling  of  Peyer's 
patches,  and,  occasionally,  degenerative  change  in  the  kidneys.  The 
inflammation  in  the  eyes,  nose,  larynx,  trachea,  and  bronchi  is  a 
constant  and  integral  part  of  the  disease,  and  is  not  to  be  considered 
as  a  complication. 

The  severity  of  this  inflammation  corresponds  with  the  severity 
of  the  attack  of  measles.  In  severe  cases  in  weak  and  delicate  chil- 
dren, especially  in  hospitals,  the  inflammation  may  extend  to  the 
air  vesicles,  and  produce  bronchopneumonia,  or  the  inflammation 
in  the  pharynx  or  larynx  may  assume  a  membranous  form.  The 
severe  cases  with  m^arked  involvement  of  the  pharynx,  larynx,  or 
lungs  are  usually  complicated  with  staphylococcic,  streptococcic, 
or  pneumococcic  infection. 

An  epidemic  of  measles  in  a  hospital  where  a  large  number  of  found- 
lings are  housed  is  often  a  most  serious  disease,  owing  to  the  frail 
and  delicate  condition  of  the  young  children,  and  their  liability  to 


MEASLES 


645 


infection  with  the  streptococcus  and  pneumococcus.  From  a  personal 
experience  with  a  number  of  such  epidemics  in  the  Children's  Depart- 
ment of  the  Philadelphia  Hospital  I  am  convinced'  that  measles  is 
a  disease  to  be  dreaded  under  such  circumstances.  General  septicemia, 
due  either  to  the  pneumococcus  or  streptococcus,  may  also  occur. 

Symptoms. — Prodromes,  such  as  drowsiness,  loss  of  appetite,  rest- 
lessness, and  disturbed  sleep  are  common. 

Stage  of  Invasion. — The  onset  of  the  disease  is  gradual,  w^th  watery 
eyes,  coryza,  cough  which  is  often  croupy,  and  slowly  rising  fever, 
which  usually  reaches  104°  F.  by  the  fourth  day,  the  highest  tempera- 
ture ordinarily  coinciding  with  the  full  development  of  the  rash. 
The  catarrhal  inflammation  of  the  mucous  membranes  also  gradually 
increases,  the  eyes  become  more  watery,  photophobia  appears,  severe 
coryza  develops  with  a  croupy  cough,  hoarseness,  pain  on  swallowing, 
and  soreness  of  the  throat  due  to  congestion  of  the  tonsils  and  pharynx. 

Koplik's  spots — minute  rose-colored  spots  with  a  central  white 
speck — are  seen  on  the  mucous  membranes  of  the  cheeks  or  lips. 
The  tongue  is  coated,  headache  and  pain  in  the  back  are  common, 
and  nausea  and  vomiting  may  occur.  The  duration  of  this  catarrhal 
stage  is  usually  three  or  four  days,  although  it  may  last  only  one  or 
two  days  or  may  continue  for  seven  days.  Occasionally  the  onset 
is  sudden  with  high  fever,  vomiting,  even  convulsions,  and  severe 
respiratory  symptoms  that  suggest  acute  pneumonia.  The  symp- 
toms during  these  first  three  or  four  days  are  quite  constant,  varying 
less  than  is  the  case  in  scarlet  fever,  although  occasionally  they  differ 
greatly  from  those  described,  especially  in  children  under  three  years 
of  age.  Occasionally  the  disease  sets  in  with  a  chill  followed  by  high 
fever. 

The  temperature  in  measles  conforms  usually  to  a  definite  type. 
The  fever  increases  each  day  until  the  eruption  is  at  its  height,  and 
falls  quite  rapidly  after  the  eruption  is  fully  established. 


DAY  OF 
DISEASE 

1 

•2 

3 

4 

5 

G 

7 

«'l 

|l04 
<103 
|102 
H    101 

iioo 

1    99 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

E 

A 

h 

s/ 

\ 

f\ 

/ 

^ 

J 

f 

V 

I 

k 

A 

/ 

V 

\ 

\ 

/S 

/ 

V 

\ 

Fig.  68. — Typical  Fahrenheit  temperature  chart  of  measles  in  a  child  of  six  years; 
rash  over  entire  body  on  evening  of  fourth  day. 


Occasionally  the  fever  is  high  at  the  onset — 103°  F. — falls  to  100° 
F.  on  the  second  day,  rises  to  102°  F.  on  the  third  day,  and  again 
reaches  104°  F.  with  the  appearance  of  the  rash  on  the  fourth 'day. 
A  decline  of  the  temperature  on  the  second  or  third  day  may  lead  to 


646  THE  SPECIFIC  INFECTIOUS  DISEASES 

an  error  in  diagnosis  unless  one  appreciates  that  the  gradual  increase 
in  the  severit}-  of  the  catarrhal  symptoms  is  of  great  significance. 
The  symptoms  and  fever  are  most  marked  at  the  time  the  eruption 
appears.  During  this  stage  of  invasion,  the  diagnosis  can  usually 
be  verified  b\'  Koplik's  spots.  If  the  mucous  membrane  of  the  mouth 
is  exammed  in  a  strong  sunlight,  a  few  or  many  stellate  or  round  rose 
spots  are  seen,  and  in  the  centre  of  each  is  a  bluish-white  speck.  They 
appear  from  one  to  three  days  before  the  rash  on  the  ^kin,  usually 
on  the  umer  surface  of  the  cheeks  and  lips,  and  are  of  great  assistance 
in  forming  an  early  diagnosis;  occasionally,  they  do  not  appear  until 
the  rash  is  present,  and  they  cannot  be  detected  by  artificial  light. 

Stage  of  Eruption. — ^The  rash  is  first  seen  on  the  upper  portion  of 
the  forehead,  behind  the  ears,  or  on  the  neck,  spreads  over  the  face 
and  scalp,  and  gradually  extends  over  the  trunk,  arms,  and  legs. 
From  the  time  of  its  first  appearance  until  the  entire  body  is  covered 
is  usually  about  thirty-six  hours.  AYhen  first  seen  it  consists  of  small 
scattered  red  spots  or  macules,  which  rapidly  mcrease  in  number, 
coalesce,  and  form  slightly  elevated  papules.  The  rash  is  irregular  in 
shape,  often  crescentic  or  oval;  some  blotches  are  large,  others  small, 
with  more  or  less  normal  or  slightly  reddish  skin  intervening  between 
the  areas  of  rash.  On  the  face  the  eruption  is  usually  confluent,  and 
the  swollen  face  with  discharging  nose  and  eyes  is  very  characteristic. 
The  rash  disappears  on  pressure,  except  in  those  cases  where  its  color 
is  a  rather  dark  red,  owing  either  to  severe  congestion  of  the  vessels 
or  to  hemorrhage.  This  does  not  necessarily  mean  that  the  child  is 
suffering  from  more  than  a  moderately  severe  case.  I  have  not 
infrequently  seen  this  hemorrhagic  rash  in  cases  of  measles  that 
were  of  ordinary  type  and  ran  the  usual  com"se;  sometimes,  however, 
these  cases  were  more  than  ordinarily  severe.  Cases  with  a  rash 
that  is  more  or  less  hemorrhagic  must  be  carefully  differentiated  from 
the  true  hemorrhagic  and  the  malignant  forms  of  the  disease. 

The  rash  remams  at  its  height  for  twenty-four  to  thirty-six  hom-s, 
and  then  begms  to  fade,  disappearing  first  from  those  portions  where 
it  appeared  first,  as  the  face  and  neck,  and  remammg  latest  on  the  lower 
extremities.  It  is  often  seen  on  the  palms  of  the  hands  and  soles  of  the 
feet.  After  the  disappearance  of  the  rash,  a  broAMiish  staining  of  the 
skin  persists  for  about  a  week.  During  this  week,  desquamation  of  the 
entire  body  occurs  in  the  form  of  fine,  bramiy  scales,  the  scales  being 
so  minute  that  desquamation  may,  and  often  does,  pass  unnoticed. 
The  more  severe  the  rash,  the  more  noticeable  is  the  desquamation. 
During  the  spreading  of  the  rash,  the  catarrhal  symptoms,  restless- 
ness, nervous  s^TQptoms,  fever,  and  cough  are  most  severe.  The 
catarrhal  s\Tnptoms  gradually  disappear  as  the  rash  fades,  although, 
during  this  period  as  well  as  earlier  in  the  disease,  the  cough  is  often 
persistent  and  aimoying,  disturbing  the  child's  sleep  and  adding 
greatly  to  its  discomfort. 

After  the  temperature  declines  to  normal,  the  cough  more  or  less 
rapidly  lessens,  loses  its  metallic  or  croupy  character,  and  commonly 


MEASLES 


647 


disappears  during  the  second  week,  although  it  may  persist  much 
longer.  The  appetite  is  poor,  the  tongue  coated,  and  symptoms  of 
gastro-intestinal  indigestion  are  common.  The  child  complains  of 
itching  and  heat  in  the  skin,  all  the  symptoms  being  most  severe 
during  the  height  of  the  rash.  The  rash  does  not  always  follow  the 
typical  course.  It  may  be  either  distinctly  papular  or  vesicular.  The 
enanthem,  or  spots  on  the  mucous  membrane,  may  not  appear;  in 
rare  cases  the  rash  on  the  skin  may  be  absent,  although  all  the  other 
symptoms  appear.  In  mild  cases  the  rash  may  be  slight,  of  short 
duration,  and  followed  by  little  or  no  desquamation.  It  is  not  uncom- 
mon for  the  rash  to  be  darker  than  normal,  of  almost  a  purple  color, 
and  not  to  disappear  on  pressure. 

Leukocytosis  is  present  in  the  latter  part  of  the  period  of  incubation, 
but  during  or  after  the  appearance  of  the  rash  is  present  only  if  some 
complication  develops.  Conjunctivitis  persists  during  the  time  of 
eruption,  and  the  eyes  are  sensitive  to  light.  Convalescence  in  uncom- 
plicated cases  is  rapid,  and  one  w^eek  after  the  rash  is  fully  developed 
the  child  is  free  from  symptoms. 


DAY   OF 
DISEASE 

1 

•1 

~ 

4 

5 

e 

7 

8 

9 

10 

11 

12 

IS 

- 

15 

IG 

>' 

iM 

|104 
|l03 
|l02 
t  101 

1  99 

M 

E 

M    E 

" 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

E 

E 

M 

E 

M 

E 

E 

M 

E 

A 

r 

J 

\ 

^ 

f\ 

, 

f\ 

A 

A 

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r 

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t 

^ 

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r 

7 

V 

V 

V 

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h 

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'N 

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A 

\ 

Fig.  69. — Typical  Fahrenheit  temperature  chart  in  measles  complicated  by  broncho- 
pneumonia. Temperature  normal  on  morning  of  eighteenth  day;  normal  convales- 
cence. 


Hemorrhagic  measles  is  marked  by  deep  stupor,  delirium,  and  con- 
vulsions. Hemorrhages  in  the  skin  and  mucous  membranes  occur, 
the  systemic  symptoms  are  very  severe,  and  a  fatal  issue  is  not 
uncommon.  The  so-called  malignant  cases  are  characterized  by 
hyperpyrexia,  marked  prostration,  severe  nervous  symptoms,  decided 
toxemia,  unusually  severe  mflammation  of  the  affected  mucous  mem- 
branes, and  either  no  rash  or  merely  a  few  spots  on  the  face.  It  is 
fatal  on  the  second  or  third  day.  Hemorrhages  may  occur  from  the 
mucous  membranes  of  the  nose,  mouth,  stomach,  or  bowel,  and  blood 
ma}*  appear  in  the  urine.  A  petechial  rash  may  appear.  Malignant 
measles  may  occur  in  epidemic  form,  or,  occasionally,  in  an  isolated 
case. 

Lack  of  hygiene,  general  w^eakness,  and  poor  nutrition  increase 
the  liability  to  malignant  measles,  and  the  infection  in  these  cases 
is  of  unusual  virulence.  The  lung  symptoms  may  be  severe,  the 
tongue  is  dry,  sordes    appear    on    the    teeth,  and    diarrhea    is  not 


648  THE  SPECIFIC  IXFECTIOUS  DISEASES 

uncommon.  The  eruption  is  dark  blue,  and  does  not  disappear  on 
pressure. 

Diagnosis. — Koplik's  spots,  which  in  the  large  majority  of  cases 
appear  one,  two,  and,  less  often,  four  or  five  days,  before  the  rash 
on  the  skm,  are  of  great  aid  in  forming  an  early  as  well  as  a  differ- 
ential diagnosis.  They  can  best  be  seen  mider  strong  smilight,  but 
often  must  be  carefully  searched  for.  These  spots  are  slightly  raised 
and  firmly  adherent,  but  can  be  removed  by  firm  rubbing  or  by 
forceps.  They  disappear  soon  after  the  appearance  of  the  rash. 
Leukopenia,  coryza,  and  fever  are  present  at  this  early  period,  and 
a  diazo-urinary  reaction  when  the  rash  appears  on  the  skin. 

Rubella  may  closely  resemble  a  very  mild  attack  of  measles,  and 
a  mild  case  of  measles  may  be  mistaken  for  rubella,  but  in  rubella 
Koplik's  spots  do  not  appear,  there  are  few  prodromes,  and  none, 
or  very  mild  catarrhal  symptoms.  The  fever  is  usually  101°  F.  or 
lower,  and  is  much  shorter  in  duration.  The  rash  is  paler  and  smaller, 
spreads  quickly,  and  does  not  persist  as  long  as  in  measles. 

Cases  of  scarlet  fever  in  which  the  skin  eruption  is  atypical  and 
resembles  measles  can  also  be  differentiated,  as  Koplik's  spots  are 
not  present.  The  rash  of  sepsis  may  closely  resemble  measles;  but, 
as  a  rule,  it  is  not  as  regularly  distributed  as  in  measles,  being  more 
apt  to  be  on  the  extensor  surface  of  the  extremities,  and  the  catarrhal 
symptoms  of  measles  are  absent.  Serum  rashes  can  be  similarly 
differentiated.  The  rashes  occasionally  produced  by  quinme,  antipyrine, 
the  salicylates,  and  turpentine  may  more  or  less  closely  resemble  the 
rash  of  measles,  but  theu'  distribution  is  usually  irregular,  and  neither 
fever  nor  catarrhal  symptoms  appear. 

Complications  and  Sequelae. — In  private  practice,  in  robust  children, 
where  the  cliild  is  seen  early,  and  receives  skilful  nursmg  and  system- 
atic treatment,  few  complications  occur.  If,  however,  the  child  is 
delicate  and  under  three  years  of  age,  complications  are  more  common 
and  more  dangerous.  I  have  had  the  opportunity  of  observing  a 
number  of  epidemics  of  measles  in  the  Children's  Department  of 
the  Philadelphia  Hospital,  and  in  hospital  practice,  especially  in 
delicate  and  poorly  nourished  children  under  three  years  of  age, 
complications  are  common  and  often  serious,  and  the  mortality  is 
high.  Older  children  in  hospitals  do  much  better;  complications  are 
less  common,  less  severe,  and  less  dangerous. 

Respiratory  Systevi. — Catarrhal  inflammation  of  the  larynx  is 
present  in  the  majority  of  cases,  severe  laryngitis  is  not  uncommon, 
and  membranous  laryngitis  occasionally  occurs,  being  seen  more 
often  in  hospital  than  in  private  practice.  It  may  be  streptococcic 
or  diphtheritic.  The  membrane  may  appear  in  the  pharynx,  may  be 
limited  to  the  larynx,  or  may  be  present  in  both  pharynx  and  larynx. 
The  tendency  to  membranous  laryngitis  is  much  greater  in  measles 
than  in  scarlet  fever.  Severe  streptococcic  infection  of  the  throat 
may  produce  marked  local  and  systemic  s^TQptoms,  and  may  cause 
death  by  a  widespread  streptococcic  infection;  moreover,  as  broncho- 


MEASLES  649 

pneumonia  is  often  associated  with  a  streptococcic  infection,  this 
dangerous  complication  may  be  added.  Streptococcic  laryngitis  is 
usually  associated  with  bronchopneumonia. 

If  membranous  inflammation  of  the  larynx  is  suspected,  cultures 
should  be  taken  immediately,  and  diphtheria  antitoxin  at  once  given. 
The  pseudomembrane  that  develops  in  the  larynx  previous  to  and 
during  the  stage  of  eruption  is  usually  due  to  the  streptococcus; 
the  membrane  that  develops  later  than  this  is  usually  true  diphtheria. 
Both  are  much  more  common  in  hospital  than  in  private  practice, 
and  most  frequent  in  children  under  four  years  of  age.  Measles 
following  diphtheria  is  not  especially  dangerous;  Hellstrom  had  8 
deaths  in  117  cases.  Diphtheria  following  measles  is  much  more 
serious,  often  being  laryngeal  in  these  cases,  and  early  treatment  with 
diphtheria  antitoxin  is  necessary  if  life  is  to  be  saved. 

Broncho'pneumonia  is  the  most  common  and  the  most  important 
complication  of  measles,  being  seen  much  more  often  and  being  more 
dangerous  in  hospital  than  in  private  practice.  The  younger  the  child 
the  greater  the  danger,  especially  in  children  under  four  years  of  age. 
Most  of  the  deaths  from  measles  are  due  to  bronchopneumonia; 
even  when  pneumonia  is  not  the  direct  cause  of  death,  more  or  less 
pneumonia  is  revealed  at  autopsy.  This  is,  however,  only  what  might 
be  expected,  since  bronchitis  is  present  in  all  cases  of  measles,  and 
the  tendency  in  children,  especially  if  frail  and  delicate,  to  develop 
secondary  bronchopneumonia  is  very  common. 

Lobar  pneumonia  is  occasionally  a  complication  in  older  children, 
and  usually  ends  in  recovery.  Pleurisy,  either  serous  or  purulent, 
may  be  associated  with  pneumonia,  and  increases  the  gravity  of 
the  prognosis.  The  association  of  measles  and  tuberculosis  is  not 
uncommon.  Tuberculous  meningitis  and  miliary  tuberculosis  fre- 
quently follow  measles,  but  tuberculous  bronchopneumonia  is  the 
most  common  tuberculous  sequel.  While  it  is,  of  course,  possible 
that  the  tuberculous  infection  may  occur  subsequent  to  the  develop- 
ment of  the  measles,  it  is  nevertheless  true  that,  in  the  large  majority 
of  cases,  latent  tuberculosis  had  previously  existed,  and  the  infection 
of  measles,  with  the  general  catarrhal  inflammation  of  the  upper 
respiratory  tract,  had  lighted  up  and  made  active  this  previously 
latent  tuberculous  process.  Tuberculosis  of  the  bones  and  of  the 
cervical  lymphatics  are  unusual  sequelae 

Otitis  is  less  apt  to  occur  and  is  less  severe  than  in  scarlet  fever; 
but  is  more  common  in  children  under  four  years  of  age.  Usually 
both  ears  are  involved,  but  without  serious  damage. 

Stomatitis. — Catarrhal  stomatitis  is  general  y  present,  and  herpetic 
and  ulcerative  stomatitis  occasionally  occur.  Gangrenous  stomatitis, 
or  noma,  is  fortunately  very  rare,  although  it  occurs  more  often  with 
measles  than  with  any  other  disease.  It  is  a  very  dangerous  compli- 
cation, but,  if  recognized  early  and  energetically  treated,  is  not  neces- 
sarily fatal.  It  is  rare  outside  of  institutions  and  hospitals.  Slight 
gangrene  of  the  face,  ears,  genitals,  and  toes  is  not  rare. 


650 


THE  SPECIFIC  IXFECTIOUS  DISEASES 


Eyes. — ^An  ordinary  catarrhal  conjuncti^"itis  is  present  in  almost 
every  case,  and  in  institutions,  or  in  weak  and  badly  noui'ished  chil- 
dren, this  inflammation  shows  a  tendency  to  continue  and  become 
chronic.  Blepharitis  and  keratitis,  acute  or  chronic,  may  occur. 
Choroiditis  is  unusual. 

Digestive  System. — Loss  of  appetite  is  common.  Diarrhea  is  of 
frequent  occurrence,  especially  after  the  fading  of  the  rash,  and  may 
be  mild  or  severe,  and  in  young  children  is  especially  common  in  hot 
weather.  Its  prompt  treatment  is  important,  as,  in  the  young  and 
poorly  nourished,  it  may  prove  a  serious  complication. 

Nephritis  as  a  complication  of  measles  is  rare,  although  in  severe 
cases  a  trace  of  albumin  is  usualh"  found. 


Fig.  70. — Xoma,  or  gangrenous  stomatitis,  following  measles. 


Nervous  symptoms  are  not  common.  Con\'ulsions  occasionally 
occur  in  very  young  children,  and  may  be  associated  with  affections 
of  the  ear,  brain,  or  hmg. 

Cervical  adenitis  is  common,  and  may  be  subacute  or  cln-onic; 
suppuration  rarely  occurs. 

Tuberculous  adenitis  is  common,  and  myocarditis,  endocarditis  or 
pericarditis  may  develop.  The  skin  is,  as  a  rule,  not  affected  other 
than  by  the  rash;  but  furmiculosis,  pemphigoid  eruptions,  impetigo, 
and  erysipelas  are,  in  rare  cases,  complications.  ^Measles  may  be 
associated  with  diphtheria,  pertussis,  or  scarlet  fever,  and  the  associa- 
tion of  pertussis  and  measles  is  quite  common,  the  one  often  following 
the  other;  if  the  two  diseases  coexist  bronchopneumonia  is  a  common 
complication.  Hemorrhages  from  the  mucous  membranes  are  rare. 
Second  attacks  of  measles  are  extremely  rare.  A  few  cases  have 
been  reported  of  children  who  have  imdoubtedly  had  measles  twice. 
Relapses  are  more  common,  the  relapse  being  separated  from  the 
primary  attack  by  an  mtervening  period  of  a  few  days  or  weeks. 

Prognosis. — This  depends  upon  the  severity  of  the  prevailing 
epidemic  and  the  previous  health  of  the  child.    Epidemics  are  usually 


1911. 

1912. 

1913. 

1914. 

1915. 

72 

7 

49 

19 

45 

104 

19 

86 

32 

81 

96 

21 

53 

20 

38 

20 

2 

7 

4 

4 

4 

0 

1 

1 

0 

4 

1 

0 

0 

1 

305 

50 

199 

77 

169 

MEASLES  651 

more  severe  in  cold  than  in  warm  weather.  Age  is  an  important 
factor;  the  younger  the  child  the  worse  is  the  prognosis.  Measles 
among  the  well-to-do  and  educated  class  is  usually  a  mild  infection, 
and  in  robust  children  is  attended  by  but  little  danger.  Among  the 
poor  and  ignorant,  especially  if  the  child  is  frail  and  badly  nourished, 
it  is  often  a  serious  disease.  If  there  is  latent  tuberculosis,  it  may 
be  stirred  into  activity  by  an  attack  of  measles,  and  become  rapidly 
progressive. 

Number  of  Deaths  in  Philadelphia — -Measles. 
Age  period. 
Under  1  year 

1  to    2  years 

2  to    5      "  .      . 
5  to  10      "  .      . 

10  to  15  "  .  - 
15  to  20  "  .  . 
All  ages 305 

If  the  temperature  has  a  tendency  to  remain  high  after  the  rash 
begins  to  fade,  some  complication  should  be  suspected,  and  this 
often  proves  to  be  bronchopneumonia.  Severe  diarrhea  following 
measles,  especially  in  the  young  and  wasted  infant,  is  dangerous, 
particularly  in  the  hot  summer  months.  Convulsions  usually  occur 
only  in  severe  cases,  and  then  add  greatly  to  the  gravity  of  the 
prognosis. 

Eseudomembrane  in  the  pharynx  or  larynx  demands  the  immediate 
use  of  diphtheria  antitoxin,  and  I  heartily  approve  of  the  practice, 
now  so  common  in  hospitals,  and  which  I  follow  in  my  wards  in  the 
Jefferson  Hospital,  of  giving  each  child  on  admission,  an  immunizing 
dose  of  diphtheria  antitoxin.  In  institutions  where  a  large  number 
of  young  children  are  housed,  and  especially  in  foundling  asylums, 
an  outbreak  of  measles  which  attacks  most  of  the  children  over  six 
months  of  age  is  often  associated  with  an  epidemic  of  bronchopneu- 
monia, and  the  mortality  may  be  as  high  as  20  to  30  per  cent.  Eighty 
per  cent,  of  all  deaths  in  measles  occur  in  children  under  five  years 
of  age. 

Prophylaxis. — The  patient  should  be  isolated  m  an  upper  room  or, 
preferably,  in  two  rooms  with  a  bath-room.  Free  ventilation  is  of 
the  utmost  importance.  Measles  patients  require  as  much  fresh 
air  as  any  others,  and  in  my  wards  for  measles  at  the  Philadelphia 
Hospital,  as  well  as  in  my  private  practice,  an  abundance  of  fresh, 
moving  air  is  allowed.  A  sheet  is  hung  at  the  door  and  kept  wet 
with  5  per  cent,  carbolic  solution;  all  articles,  such  as  bed  linen, 
dishes,  etc.,  removed  from  the  room  should  be  immersed  in  5  per 
cent,  carbolic  solution. 

It  is  important  that  all  infants  and  young  children  be  protected 
from  the  disease,  also  all  delicate  or  badly  nourished  children,  and 
those  who  have  any  tendency  to  respiratory  diseases  or  to  tuberculosis. 

In  hospitals  and  institutions  all  measles  patients  should  be  imme- 
diately removed  from  the  ward.     The  quarantme  for  measles  should 


652  THE  SPECIFIC  INFECTIOUS  DISEASES 

be  twenty-one  days;  that  is,  the  patient  should  be  quarantined  for 
seventeen  days  from  the  day  the  rash  is  fully  developed.  At  the  end 
of  this  period  of  quarantine,  the  room  occupied  by  the  patient  should 
be  thoroughly  house-cleaned  and  disinfected,  and  the  windows  left 
open  for  tlii'ee  days  to  admit  sunshine  and  moving  fresh  air.  The 
room  may  then  safely  be  occupied  by  other  children. 

Any  children  in  the  family  where  there  is  a  case  of  measles  who 
have  been  exposed  should  not  be  allowed  to  return  to  school  mitil 
after  the  period  of  quarantine  has  expired.  In  a  hospital  ward,  the 
daily  examination  of  all  exposed  children  for  Koplik's  spots  aids  in 
the  early  recognition  of  such  patients,  and  their  temporary  isolation. 

Treatment. — The  eyes  are  cleansed  frequently  with  a  boric  acid 
wash,  and  1  per  cent,  unguentum  hydrarg\Tum  oxidum  flavum 
applied  to  the  lids.  The  nose,  mouth,  and  throat  should  be  kept 
clean  by  spraying  with  a  mild  alkaline  solution.  Liquor  alkalinus 
antisepticus,  diluted  with  fom-  parts  of  water,  is  an  agreeable  and 
efficient  preparation.  This  cleansing  has  a  tendency  to  prevent  the 
spreadmg  to  the  ears  and  larynx  of  the  catarrhal  inflammation  always 
present  in  the  nose. 

The  patient  should  be  kept  in  bed  until  the  rash  has  entirely 
disappeared  and  the  temperature  has  been  normal  for  two  or  three 
days.  He  should  have  only  enough  bedclothes  to  keep  him  comfort- 
able, and  compresses,  kept  wet  with  cold  water,  should  be  applied 
to  the  eyes.  The  child's  eyes  should  be  shielded  from  direct  sunlight, 
and  the  room  should  be  kept  rather  dark.  Dark  glasses  may  be  worn 
by  older  children. 

An  abundance  of  fresh,  cool,  moving  aii*  is  essential  unless  the 
child  has  severe  laryngitis,  when  warm,  moist  air  is  to  be  preferred. 
The  child  is  kept  on  liquid  diet  during  the  period  of  fever,  and  the 
bowels  kept  moved  each  day.  A  tepid  bath  once  or  twice  a  day, 
or  spongmg  with  a  bicarbonate  of  soda  solution,  a  teaspoonful  in 
two  quarts  of  warm  water,  will  partially  allay  the  burning  and  itching 
of  the  skin. 

The  cough  is  usually  the  most  annoying  and  distressing  symptom, 
as,  if  persistent,  it  disturbs  the  sleep  and  aggravates  the  nervous 
symptoms.  It  is  best  controlled  by  heroin,  gr.  ^V  to  -^-q,  or  codein, 
gr.  -f-Q,    or  Dover's  powder,  gr.  j  to  ij,  every   two   or  three  hoiu-s. 

Nervousness,  restlessness,  and  headache  are  best  relieved  by  gr. 
j  to  ij  of  antip\Tin  or  phenacetm,  repeated  m  three  hours  if  necessary. 
For  sleeplessness,  trional,  gr.  v,  once  in  24  hours,  is  of  service.  The 
child  should  be  given  each  day  a  warm  cleansing  bath  followed  by 
an  alcohol  rub.  If  the  fever  has  been  103°  to  104°  F.  for  only  24  to 
48  hours  at  the  time  of  the  development  of  the  rash,  it  requires  no 
special  treatment,  but  if  of  longer  duration,  and  associated  with 
restlessness  and  nervousness,  it  is  best  treated  by  an  ice-cap,  and  a 
tepid  bath,  95°  to  85°  or  80°  F.,  with  friction,  the  duration  of  the 
bath,  five  to  twelve  minutes,  depending  upon  the  resulting  reduction 
of  temper atiue. 


RUBELLA  653 

In  severe  cases,  if  the  hands  and  feet  are  cold,  they  should  be  kept 
warm  with  gloves,  stockings,  and  hot-water  bags.  Cardiac  depression 
should  be  combated  with  whisky,  f5ss  to  fsj,  every  two  to  tliree  hours; 
strychnine,  gr.  2^^o"  every  three  hours;  camphorated  oil,  gtt.  xv, 
hypodermically  every  four  hours;  tincture  of  digitalis,  gtt.  j  to  iij, 
every  six  hours,  or  caffein  citrate,  gr.  j  to  ij  every  three  hours. 

Children  with  pneumonia  as  a  complication  should  be  separated 
from  other  measles  cases.  In  hospitals  and  institutions  all  measles 
cases  should  receive  an  immunizing  dose  of  antitoxin,  and  in  private 
practice  any  suspicious  evidence  of  diphtheria  should  be  similarly 
treated.  Bronchopneumonia  should  be  treated  as  directed  under 
that  disease. 

If,  after  the  disappearance  of  the  rash,  cough  persists,  especially 
if  associated  with  fever,  bronchopneumonia  is  to  be  suspected,  and 
the  well-know^n  tendency  of  such  cases  to  become  tuberculous  should 
be  borne  in  mind.  Fresh  air,  rest,  abundance  of  nourishing  and  easily 
digested  food,  the  keeping  of  the  digestion  in  good  condition,  and  a 
suitable  climate,  with  tonics — iron,  arsenic  and  cod-liver  oil — are 
all  indicated. 

Laryngeal  symptoms  should  be  treated  with  a  croup  tent,  creosote 
being  added  to  the  water  in  the  croup  kettle.  If  the  symptoms  indi- 
cate the  development  of  laryngeal  membrane,  diphtheria  antitoxin 
should  be  given,  and  a  culture  taken.  If  fever  persists  without 
apparent  cause,  suspect  the  ears,  and  if  any  local  evidence  of  inflam- 
mation can  be  detected,  puncture  of  the  ear-drums  should  be  per- 
formed. It  does  no  harm,  and  the  escape  of  the  pus  or  sero-pus  may 
at  once  relieve  the  symptoms.  The  child  should  lie  on  the  affected 
side  after  the  puncture. 

A  child  with  bronchopneumonia  following  measles,  especially  in 
a  hospital  ward  where  there  are  other  children  between  one  and 
four  years  of  age,  should,  if  possible,  be  immediately  isolated  from 
all  other  measles  cases,  as  the  danger  of  an  epidemic  of  broncho- 
pneumonia is  well  recognized;  it  has  twice  occurred  in  my  wards 
in  the  Philadelphia  Hospital. 

RUBELLA  (ROTHELN— GERMAN  MEASLES). 

Rubella  is  a  contagious  disease  occurring  in  epidemic  form,  char- 
acterized by  mild  catarrhal  symptoms,  a  diffuse  eruption  of  rose- 
colored  macules  which  may  resemble  either  measles  or  scarlet  fever, 
a  slight  fever  lasting  three  or  four  days,  and  swelling  of  the  superficial 
posterior  cervical  lymph  glands. 

Etiology. — It  is  less  contagious  than  measles,  and  is  most  common 
in  the  winter  and  spring.  The  virus  is  longer-lived  outside  the  human 
body  than  is  the  virus  of  measles.  It  usually  occurs  in  epidemics 
which  recur  at  intervals  of  two  to  four  years,  and  is  almost,  if  not 
quite,  as  common  as  measles.  It  is  generally  transmitted  by  direct 
contact  but  can  be  carried  for  a  short  time  or  distance  bv  a  thhd 


654  THE  SPECIFIC  INFECTIOUS  DISEASES 

person  or  by  fomites.     It  is  contagious  from  the  earliest  period  of 
the  disease  until  the  disappearance  of  the  eruption. 

Infants  less  than  six  months  old  rarely  contract  rotheln,  although 
it  may  occur  before  the  age  of  six  months,  and  may  be  present  at 
birth  or  a  few  days  after  birth.  Children  between  the  ages  of  six  and 
twelve  months  are  more  susceptible  and  after  the  age  of  one  year 
all  those  exposed  to  rubella  are  likely  to  contract  it.  Like  measles, 
all  ages  are  susceptible.  The  specific  virus  of  rubella  is  as  yet 
unknown,  but  an  attack  of  rubella  does  not  protect  from  either 
measles  or  scarlet  fever. 

Symptoms. — The  period  of  incubation  varies  from  5  to  21  days, 
although  it  is  usually  10  to  20  days.  Second  attacks  and  relapses 
are  rare. 

Stage  of  Invasion. — The  symptoms  are  generally  very  trivial  and 
transient,  and  may  be  easily  overlooked.  There  is  slight  coryza, 
pharyngitis,  and  laryngitis,  associated  with  general  malaise.  The 
fever  is  moderate,  100°  F.  (37.8°  C.)  to  102°  F.  (38.9°  C).  In  the 
rather  rare  cases  where  the  children  are  quite  ill,  the  symptoms  may 
be  severe;  headache,  chills,  a  sensation  of  weakness,  pain  in  the  back, 
catarrhal  symptoms  about  as  severe  as  in  measles,  and  a  tempera- 
ture of  100°  to  103°  F.,  with  mild  delirium,  convulsions,  and  epistaxis; 
but  these  severe  cases  are  not  common.  The  prodromal  stage  lasts, 
ordinarily,  only  about  12  hours,  although  it  may  occasionally  last 
three  or  four  days.  As  a  rule  the  longer  the  stage  of  invasion,  the 
more  severe  is  the  attack. 

Stage  of  EnqAion. — The  eruption  generally  appears  in  12  hours 
after  the  initial  symptoms;  very  often  the  rash  is  the  first  sign  of 
the  disease,  the  prodromes  having  been  so  slight  that  they  passed 
unnoticed.  The  rash  usually  appears  first  on  the  face,  and  spreads 
over  the  entire  body  in  24  hours.  The  eruption  remains  at  its  height 
on  any  one  portion  of  the  body  usually  for  about  6  to  12  hours, 
and  passes  like  a  wave  over  the  face,  thorax,  abdomen,  and  extrem- 
ities. It  may  be  well-developed  on  the  face,  thorax,  and  abdomen 
before  it  has  spread  to  the  legs.  It  consists  of  small,  round,  or  oval 
macules  of  a  pale  rose-color,  slightly  elevated  and  usually  discrete, 
with  areas  of  skin  paler  in  color  intervening. 

As  the  rash  develops  it  often  becomes  confluent,  and  may  simulate 
closely  the  eruption  of  measles.  The  lesions  on  the  skin  are  usually 
smaller  and  more  regular  than  in  measles,  and  are  not  apt  to  be  cres- 
centic.  The  rash  is  more  apt  to  be  confluent  on  the  face  than  on  any 
other  portion;  it  is  quite  profuse  over  the  scalp  and  is  usually  least 
upon  the  legs.  It  fades  first  where  it  appears  first,  lasts  from  two  to 
three  days,  is  followed  by  a  fine,  bran-like  desquamation,  and  later 
by  an  indistinct  pigmentation  which  lasts  for  only  a  few  days.  In 
other  cases  the  rash  is  very  fine,  pin-head  in  size,  and  spreads  over 
portions  of  the  body  like  a  blush,  resembling  closely  the  rash  of  scarlet 
fever. 

In  rubella  and  measles  the  rash  appears  on  the  lips ;  in  scarlet  fever. 


RUBELLA  655 

the  margin  of  skin  around  the  mouth  is  usually  free  from  rash.  There 
is  slight  itching  and  the  posterior  cervical  lymph  glands  are  enlarged; 
usually,  however,  the  lymphatic  swelling  persists  for  only  a  few  days. 
The  spleen  is  usually  moderately  enlarged;  slight  cough,  a  mild  phar- 
yngitis, slight  laryngitis,  coated  tongue,  and  occasional!}^  nausea 
and  vomiting  are  present. 

The  severity  of  the  symptoms  varies  greatly  in  different  epidemics 
and,  while  the  fever  and  constitutional  symptoms  are  usually  mild, 
epidemics  have  been  reported  where  temperatures  of  102°  to  104°  F. 
were  common  and  associated  with  well-marked  eruption  and  severe 
catarrhal  and  nervous  symptoms. 

Forcheimer  has  described  an  enanthem  which  lasts  for  24  hours 
or  less.  The  enanthem  is  seen  upon  the  uvula,  soft  palate,  and, 
less  often,  on  the  hard  palate.  It  consists  of  macules  of  pink  rose- 
red  color,  the  spots  are  the  size  of  large  pin-heads,  and  are  only  slightly 
elevated  above  the  mucous  membrane.  The  prodromal  period  of 
rubella  is  short,  usually  about  12  hours,  and  this  enanthem  which 
appears  and  fades  away  in  the 'first  24  hours  is  present  at  or  before 
the  time  the  rash  is  appearing  on  the  skin,  so  that  at  the  most  only  a 
few  hours  intervene  between  the  appearance  of  the  enanthem  and 
the  exanthem.  It  is  important  to  remember  that  the  enanthem  only 
persists  for  12  to  24  hours. 

Diagnosis. — It  is  the  variations  in  the  rash  that  usually  cause  one 
to  hesitate  in  making  a  diagnosis  in  the  exanthemata,  and  in  those 
cases  where  the  rash  is  irregular  and  atypical,  the  diagnosis  must 
often  be  made  from  studying  the  period  of  incubation,  the  prodromes, 
the  initial  and  usual  symptoms,  the  duration  of  the  rash,  the  character 
of  the  desquamation,  and  the  complications  and  sequelae.  In  a  doubt- 
ful case  it  is  best  to  quarantine  and  withhold  the  diagnosis  for  a  few 
days. 

Rubella  is  to  be  diagnosed  from  measles  and  scarlet  fever,  and  while 
this  is  usually  an  easy  matter,  in  some  cases  it  is  difficult.  If  an 
epidemic  of  rubella  exists,  the  diagnosis  is  simplified.  Rubella  shows 
a  slight  fever,  an  enlarged  spleen,  enlarged  posterior  cervical  lym- 
phatics, an  eruption  that  appears  in  the  first  12  hours,  and  is  of  short 
duration,  and  a  rose-pink  enanthem,  the  size  of  large  pin-heads,  on 
the  uvula  and  soft  palate,  that  appears  either  slightly  before  or  at 
the  time  of  the  rash,  and  lasts  for  six  to  12  or  24  hours. 

Measles  has  well-marked  catarrhal  symptoms,  a  higher  fever, 
rash  on  the  third  and  fourth  day,  an  eruption  that  persists  longer  and 
is  often  crescentic,  Koplik's  spots,  and  more  frequently  complications, 
especially  bronchopneumonia.  The  difficulty  arises  in  differentiating 
a  mild  case  of  measles,  with  very  slight  prodromes  and  moderate 
fever,  mild  catarrhal  symptoms  and  slight  rash,  from  a  severe  case 
of  rubella. 

In  such  cases,  if  there  is  an  epidemic  of  measles,  if  the  period  of 
incubation  is  definitely  known  to  have  been  11  days  before  the 
catarrhal  symptoms,  and  14  days  before  the  rash  appeared,  these 


656  THE  SPECIFIC  INFECTIOUS  DISEASES 

facts,  and  the  knowledge  that  the  catarrhal  symptoms  even  m  a 
mild  attack  of  measles  are  usually  much  more  severe  than  in  a  severe 
attack  of  rubella,  point  strongly  to  the  diagnosis  of  measles  and  not 
rubella. 

If  the  eruption  of  rubella  is  of  the  scarlet-fever  type,  it  may  be 
impossible  to  make  a  diagnosis  from  the  appearance  of  the  rash.  If, 
however,  other  features  of  the  case  are  studied,  a  correct  diagnosis 
is  usually  possible.  Scarlet  fever  has  a  shorter  period  of  incubation 
(from  three  to  seven  days),  the  initial  symptoms  usually  develop 
suddenly  and  are  severe,  with  high  fever,  104°  F.,  and  severe  throat 
symptoms,  and  the  enlarged  cervical  glands  are  at  the  angle  of  the 
jaw.  There  is  pallor  around  the  mouth,  and  a  white  line  appears  at 
the  union  of  the  finger-nail  and  pulp  of  the  finger.  The  eruption 
persists  for  five  or  six  days,  and  the  desquamation  is  in  flakes.  The 
typical  strawberry  tongue  is  present,  and  ear  and  kidney  complica- 
tions are  common. 

Com.plications  and  Sequelse. — The  disease  is  so  mild  that  compli- 
cations are  rare.  Albuminuria,  stomatitis,  bronchitis,  bronchopneu- 
monia, erysipelas,  and  severe  sore  throat  are  occasionally  seen.  Less 
often,  plem-isy,  enteritis,  rheumatism,  endocarditis,  otitis  and  eye 
complications  develop. 

Treatment. — The  child  should  be  isolated  and  quarantine  should 
be  maintained  for  two  weeks.  In  hospitals  or  institutions,  infants 
over  six  months  of  age,  and  young  children  should  be  especially  pro- 
tected from  the  disease.  The  child  should  be  kept  in  bed  until  the 
rash  has  entirely  disappeared,  should  be  given  liquid  nourishment, 
the  bowels  should  be  moved  each  day,  and  any  symptoms  which 
develop  should  receive  appropriate  treatment. 

DIPHTHERIA. 

Diphtheria  is  an  acute  infectious  disease  characterized  by  the 
production  of  a  false  membrane  on  the  mucous  surfaces  of  the  throat 
or  respiratory  passages.  The  tonsils,  soft  palate,  pillars  of  the  fauces, 
the  uvula,  the  pharynx,  and  the  nares  are  the  parts  most  frequently 
affected.  The  larynx  is  often  involved,  either  primarily  or  by  exten- 
sion, and  the  disease  may  be  limited  to  this  one  part. 

In  mild  cases  constitutional  symptoms  may  be  totally  absent,  but 
in  severe  forms  there  is  marked  prostration  and  cardiac  depression. 
Frequently  pneumonia  and  nephritis  are  complications,  and  paralysis, 
local  or  general,  may  follow.  Diphtheria  occurs  endemically,  epi- 
demically, and  sporadically,  and  is,  perhaps,  less  contagious  than 
most  of  the  other  acute  infections  of  childhood. 

Etiology. — The  disease  is  the  result  of  infection  by  a  specific  micro- 
organism, and  is  at  first  local;  later,  as  the  result  of  absorption  of 
toxins  produced  by  the  bacilli,  it  becomes  systemic. 

The  Bacillus  diphtlierice,  also  known  as  the  Klebs-Loeffler  bacillus, 
was  first  described  by  Klebs  in  1883,  and  later  isolated  by  Loeffler. 


DIPHTHERIA  657 

The  organism  is  rod-shaped  with  rounded  ends,  and  is  either  straight 
or  shghtly  curved,  varying  in  diameter  from  0.5  to  0.8  micron,  and  in 
length  from  2  to  3  microns.  These  bacilH  vary  greatly  in  form,  and 
in  the  same  specimen  may  be  found  either  singly  or  in  pairs.  Some- 
times they  form  chains  or  parallel  lines,  and  often  an  obtuse  angle. 

The  culture  medium  used  influences  greatly  the  form  and  size, 
the  bacilli  appearing  smallest  and  most  regular  on  glycerin  agar, 
and  as  segmented  regular  staining  forms  when  grown  upon  Loeffler's 
blood  serum.  The  bacillus  stains  well  with  ordinary  aniline  dyes 
and  with  the  Gram  stain.  The  stain  most  frequently  used  is  Loeffler's 
alkaline  solution  of  methylene  blue,  which  makes  the  granules  easily  seen. 

In  1897,  Neisser  advocated  the  following  method  of  staining  in 
order  to  differentiate  the  bacillus  from  other  organisms  which  may 
closely  simulate  it.  As  described  by  Abbott  it  is  as  follows:  The 
culture  tested  should  be  grown  upon  Loeffler's  blood-serum  mixture, 
solidified  at  100°  C.  It  should  develop  at  a  temperature  not  lower 
than  34°  C.  or  higher  than  36°  C,  and  should  not  be  younger  than 
nine,  or  older  than  twenty-four  hours.  A  cover-glass  preparation 
is  made  from  such  a  culture,  and  stained  from  one  to  three  seconds 
in  the  following  solution : 

Methylene  blue  (Grubler's) 1  gram 

Alcohol  (96  per  cent.) 20  c.c. 

When  dissolved,  mix  with : 

Acetic  acid      .      .- 50  c.c. 

Distilled  water '    .     950  c.c. 

The  preparation  is  thoroughly  rinsed  in  water,  and  then  stained  from 
three  to  five  seconds  in  vesuvin  (Bismarck  brown),  2  grams  dissolved 
in  a  liter  of  distilled  water,  filtered,  and  allowed  to  cool.  It  is  again 
rinsed  in  water,  and  is  examined  as  a  water  mount,  or  dried  and 
mounted  in  balsam.  The  bacilli,  when  stained  in  this  manner,  appear 
as  faintly  stained  brown  rods  in  which  can  be  seen  one  to  three  brown 
granules.  The  granules  are  usually  oval,  occupy  one  or  both  poles  of 
the  cell,  and  bulge  slightly  beyond  the  contour  of  the  bacillus  in 
which  they  are  found.  In  most  instances  the  bacilli  that  do  not 
stain  in  this  manner  are  considered  distinct  from  diphtheria  organisms 
(Abbott).  The  bacillus  is  non-motile,  aerobic,  liquefying,  and  does 
not  form  spores.  It  is  also  a  facultative,  anaerobic  organism  (Stern- 
berg). In  the  dry  state  it  maintains  its  vitality  for  a  long  period  of 
time.  Abel  found  bacilli  on  children's  toys,  which  had  been  kept  in 
the  dark,  five  months  after  exposure. 

The  diphtheria  bacillus  may  be  found  in  the  heart's  blood,  lungs, 
liver,  spleen,  kidneys,  and  lymph  nodes,  and  is  more  easily  demon- 
strated in  these  organs  when  the  cases  are  uncomplicated.  When 
diphtheria  complicates  scarlet  fever,  measles,  and  other  diseases, 
there  is  usually  a  mixed  infection,  and  staphylococci  and  streptococci 
are  found,  in  addition  to  the  Klebs-Loeffler  bacillus. 
42 


658  THE  SPECIFIC  INFECTIOUS  DISEASES 

Modes  of  Communioaticn. — All  cases  of  the  disease  have  their  origin 
in  a  previous  case,  either  recognized  or  unrecognized.  An  individual 
may  become  infected  by  organisms  in  the  air,  or  they  may  be  taken 
into  the  mouth  by  kissing,  or  by  the  handling  of  toys,  infected  clothing, 
or  other  articles  upon  which  they  may  have  lodged. 

Occasionally  diphtheria  organisms  are  found  in  the  throats  of 
apparently  healthy  individuals  without  their  having  contracted  the 
disease.  Such  persons  are  known  as  diphtheria  carriers,  and  may 
be  a  source  of  infection  to  others.  But  there  seems  to  be  much  evi- 
dence in  favor  of  the  theory  that  there  are  non-pathogenic  as  well  as 
pathogenic  diphtheria  bacilli;  unquestionably  there  is  a  great  differ- 
ence in  the  virulence  of  the  various  types. 

Pharyngeal  diphtheria  is  more  contagious  than  other  types  because 
of  the  excessive  amount  of  discharge  laden  with  the  organisms,  which 
may  readily  be  a  means  of  infecting  others.  It  is  sometimes  com- 
plicated by  retropharyngeal  abscess,  the  result  of  streptococcic 
infection  of  the  lymph  nodes  in  that  region. 

A  patient  suffermg  with  diphtheria  may  convey  the  disease  to  others 
for  some  time  after  the  disappearance  of  the  membrane.  In  some 
instances  organisms  have  been  found  in  the  throat  six  to  eight  weeks 
after  recovery.  In  large  cities  the  presence  or  absence  of  bacilli  in 
the  throat  after  the  termination  of  the  disease  is  determined  by  means 
of  a  culture.  Usually  two  negative  cultures,  taken  on  successive  days, 
and  at  least  twenty-foiu-  hours  apart,  are  reciuired  before  the  quaran- 
tine is  removed,  provided  fourteen  days  have  elapsed  from  the  date 
of  onset.  It  is  essentially  a  disease  of  children,  and  occurs  only 
occasionally  in  adults.  It  is  less  common  in  the  first  year  of  infancy 
than   in   older   children. 

Individuals  are  frequently  infected  directly  through  furniture, 
hangings,  dishes,  spoons,  and  other  articles  which  have  been  in  con- 
tact with  a  patient  suffering  from  the  disease.  INIilk  m.ay  be  a  mode 
of  transmitting  diphtheria,  and  in  rare  instances  water.  The  chief 
predisposing  factors  in  children  are  enlarged  tonsils  and  adenoid 
growths  in  the  pharynx.  The  bacilli  may  lodge  in  the  crypts  of  the 
tonsils  and  in  the  cavities  of  decayed  teeth,  and  remain  there  for  som.e 
time.  Certain  of  the  acute  infectious  diseases,  particularly  measles 
and  scarlet  fever,  so  affect  the  mucous  m.embranes  as  to  m.ake  them 
extremely  susceptible  to  diphtheria.  It  is  most  prevalent  during  the 
winter  and  autumn  months.  Predisposing  factors  are  unhygienic 
surroundings,  exposure  to  cold  and  dampness,  faulty  sanitation, 
overcrowding,  neglect  of  the  teeth  and  mouth,  and  chronic  catarrhal 
conditions  of  the  nose  and  throat.  One  attack  in  no  way  confers 
immunity  against  subsequent  attacks  of  the  disease. 

Children  between  the  ages  of  two  and  six  years  are  more  susceptible 
than  any  others,  susceptibility  becoming  less  after  ten  years  of  age. 

Period  of  Incubation. — This  period  varies  according  to  the  virulence 
of  the  organism  and  the  resistance  of  the  individual.  From  two  to 
five  days  usually  elapse  before  the  disease  manifests  itself.     Con- 


DIPHTHERIA  659 

stitutional  symptoms  do  not  appear,  as  a  rule,  until  after  the  character- 
istic exudate  is  seen.  Nevertheless,  in  the  majority  of  instances,  the 
period  of  incubation  is  short. 

Sjrmptoms. — Frequently  there  are  slight  prodromes,  such  as  head- 
ache, anorexia,  nausea,  vomiting,  and  general  malaise,  prior  to  the 
appearance  of  characteristic  symptoms.  The  lymphatic  glands  near 
the  angle  of  the  jaw  may  becom.e  tender,  and  there  may  be  slight 
difficulty  in  swallowing.  Sometimes  convulsions  may  be  the  only 
symptom  to  usher  in  the  disease.  There  is  slight  elevation  of  tem.pera- 
ture,  frequently  accompanied  by  a  sense  cf  chilliness.  Gastro-intestinal 
disturbances  are  usually  of  no  moment.  In  the  laryngeal  form  the 
earliest  symptom  is  huskiness  of  the  voice,  which  is  noticeable  long 
before  the  appearance  of  the  membrane,  and  is  usually  accompanied 
by  a  brassy  cough  together  with  dyspnea  due  to  slight  laryngeal 
spasms. 

The  Throat. — In  the  throat,  as  a  rule,  is  seen  the  first  evidence  of  diph- 
theria, the  tonsils  being  the  favorite  seat  for  lodgement  and  multiplica- 
tion of  the  organisms.  Usually  the  tonsils  are  swollen,  the  fauces 
congested,  and  on  the  surface  of  the  tonsils  and  in  their  crypts  may  be 
seen  spots  of  exudate  which  rapidly  spread  and  coalesce,  often  covering 
the  entire  tonsil.  In  the  severe  forms,  especially  when  both  tonsils  are 
involved,  the  exudate  has  a  tendency  to  spread  to  the  fauces,  covering 
both  the  anterior  and  posterior  pillars,  also  the  posterior  wall  of  the 
pharynx,  uvula,  and  soft  palate.  The  nares  and  larynx  often  become 
involved. 

The  exudate  itself  is  either  yellowish-white  or  dark  gray,  may  be 
either  thick  or  thin,  and  is  usually  extrem.ely  adherent,  so  much  so 
that  when  removed  it  frequently  leaves  a  bleeding  surface.  A  distinct 
odor  is  observable  after  a  few  days,  and  often  this  alone  m.akes  one 
suspect  the  presence  of  the  disease. 

Microscopically  the  membrane  is  found  to  consist  of  a  network  of 
fibrin,  enclosing  within  its  meshes  epithehal  and  round  cells  which 
show  evidences  of  degeneration;  in  the  superficial  layer  are  usually 
found  a  variety  of  other  organisms  as  well  as  diphtheria  bacilli.  The 
epithelial  cells  of  the  affected  mucous  mem.branes  show  degeneration 
with  fragmentation  of  the  nuclei,  and  there  is  leukocytic  infiltration  of 
the  mucosa  which  sometim.es  extends  into  the  submucous  and  muscular 
layers. 

In  some  cases  there  is  a  resem.blance  to  follicular  tonsillitis,  with 
practically  no  mero.brane  form.ation,  the  fauces  exhibiting  m.erely  an 
angina.  The  larynx  is  rarely  involved  in  the  mild  and  localized  cases, 
and  there  may  be  few,  if  any,  symptoms  referable  to  the  throat,  so 
that,  unless  discovered  on  system.atic  examination  of  the  throat,  the 
diphtheritic  aspects  of  these  cases  m.ay  pass  unrecognized. 

In  certain  other  types  the  diphtheritic  lesions  appear  as  strips  and 
specks  of  exudate  scattered  over  the  tonsils,  uvula,  and  posterior 
pharyngeal  wall.  These  cases  usually  present  mild  constitutional 
symptoms,  and  are  most  common  in  older  children.     The  onset  is 


660  THE  SPECIFIC  INFECTIOUS  DISEASES 

gradual,  and  is  accompanied  by  a  slight  feeling  of  malaise  and  sore 
throat.  The  temperature  rises  to  101°  or  102°  F.,  and  the  lymph  nodes 
behind  the  jaw  become  slightly  enlarged. 

In  some  cases  the  children  do  not  go  to  bed,  so  mild  are  the  symp- 
toms. When  these  mild  localized  forms  occur  during  infancy,  gastro- 
intestinal manifestations  often  predominate,  and  there  may  be  few 
symptom.s  referable  to  the  throat,  except  slight  swelling  of  the  lymph 
nodes  at  the  angle  of  the  jaw.  The  fever  ranges  from  101°  to  102°  F., 
and  the  pulse  and  respiration  are  accelerated.  In  many  infantile 
diphtherias,  anorexia,  and  diarrhea  wdth  green,  foul-smelling  stools 
are  the  most  marked  symptoms.  Owing  to  the  prompt  recognition  of 
diphtheria  and  the  liberal  use  of  antitoxin,  the  majority  of  cases  do 
not  progress  beyond  this  mild  stage. 

Severe  types  do  occur,  however,  and  in  these  instances  the  membrane 
not  only  forms  extensively  in  the  throat,  but  may  also  be  in  the  nose, 
and  occasionally  in  the  larynx.  The  membrane  changes  from  a 
grayish-white  to  a  dirty  greenish  hue,  and  the  child  becomes  extremely 
toxic.  There  is  notable  depression  of  the  pulse,  also  extreme  prostra- 
tion, difficulty  in  breathing,  great  swelling  of  the  cervical  glands, 
and  of  the  lymph  nodes  at  the  angle  of  the  jaws.  The  temperature 
is  at  no  tim.e  very  high,  and  varies  between  101°  and  102°  F.  throughout 
the  greater  part  of  the  attack. 

The  child  is  apathetic,  with  spells  of  extreme  restlessness,  has  no 
appetite,  suffers  pain  on  swallowing,  vomits  w^henever  it  attempts  to 
eat,  and  frequently  has  diarrhea.  Pain  in  the  back  and  headache  are 
usually  quite  severe. 

Albuminm-ia  is  always  present  in  these  cases,  and  not  infreciuently 
hyaline  and  granular  casts  may  be  found  in  the  urine.  In  the  severe 
t^'pes  of  diphtheria,  a  Avell-marked  diffuse  nephritis  occasionally 
causes  death. 

Nasal  Diphtheria. — The  jwse  is  the  common  seat  of  involvement, 
after  the  fauces.  Although  the  lesions  here  are  frequently  primary, 
the  nose  more  often  becomes  involved  by  extension  of  the  exudate 
from  the  throat.  The  mouth  is  kept  open,  the  child  snores,  has  a 
foul  breath,  and  is  almost  unable  to  swallow.  As  the  membrane 
increases  in  thickness,  the  nasal  cavities  become  occluded,  and  prevent 
the  discharge  from  escaping;  it  now  changes  from  a  serous  type,  and 
becomes  ichorous  and  blood-stained.  This  in  tiu-n  prevents  nasal 
breathing,  and  gives  to  the  voice  a  nasal  tone.  On  examination  of  the 
nose  a  whitish  or  greenish  mem.brane  is  seen,  and  the  anterior  nares 
are  eroded.  After  the  detachment  and  expulsion  of  the  membrane, 
which  may  sometimes  be  in  the  form  of  a  distinct  cast,  there  is  a 
return  of  the  nasal  discharge,  which  may  be  copious. 

In  considering  the  subject  of  nasal  diphtheria  it  is  important  to 
remember  that  the  Klebs-Loeffler  bacillus  may  produce  only  the 
slightest  irritation  and  discharge,  no  membrane  being  present;  or 
it  may  produce  the  most  intense  inflammation  with  swelling  and 
edema  and  membrane  so  extensive  in  amount  as  to  more  or  less  com- 


DIPHTHERIA  661 

pletely  block  the  nares.  The  amount  of  contagion  is  usually  in  duect 
proportion  to  the  amount  of  discharge  from  the  nose  and  nasopharynx. 
However,  diphtheria  may  be,  and  not  uncommonly  is,  spread  from  a 
case  where  little  or  no  discharge  is  present,  and  yet  Klebs-Loeffler 
bacilli  in  small  or  large  numbers,  and  virulent,  may  be  demonstrated 
as  present  in  the  nose. 

When  one  considers  that  these  cases  are  apt  to  be  overlooked; 
are  not  ill  enough  to  wish  to  be  confined  to  bed  or  within  a  certain 
room  or  rooms;  have  perhaps  very  slight  local  manifestations  and 
no  constitutional  symptoms,  it  is  not  to  be  wondered  at  that  par- 
ents fail  to  see  the  necessity  for  strict  isolation,  and  that  a  more 
or  less  casual  examination  by  the  physician  does  not  disclose  the 
real  nature  of  the  affection;  and  as  membrane  is  more  commonly 
limited  to  the  posterior  than  to  the  anterior  nares,  its  presence  may  be 
overlooked. 

Such  cases  are  often  the  focus  from  which  epidemics  in  a  school 
or  hospital  ward  may  have  their  origin,  and,  while  perhaps  not  danger- 
ous to  the  infected  individual,  are  a  great  menace  to  the  community. 
It  is  impossible  to  say  in  any  given  case  how  long  the  contagion  may 
exist,  whether  a  severe  inflammation  with  membrane  and  profuse  dis- 
charge is  present,  or  a  mild  case  with  slight  angina  and  no  membrane; 
but  it  is  absolutely  necessary,  for  the  safety  of  others,  that  all  such 
cases  should  be  isolated  until  no  local  manifestations  remain,  and  all 
the  diphtheria  bacilli  have  disappeared. 

If,  however,  as  will  occasionally  happen,  the  bacilli  are  found  for 
more  than  a  reasonable  time,  say  two  weeks  after  all  local  evidences 
of  the  disease,  such  as  membrane,  inflammation  and  discharge,  have 
disappeared,  then  it  is  quite  possible  that  these  bacilli  are  not  virulent 
and  a  guinea-pig  should  be  inoculated,  to  test  their  virulence.  It  is 
also  necessary  to  draw  particular  attention  to  the  fact  that  it  is  often 
extremely  difficult  to  distinguish  between  the  true  and  pseudodiph- 
theritic  bacillus,  many  bacteriologists  claiming  that  it  may  be  impos- 
sible to  do  so.  If  inoculations  with  guinea-pigs  were  more  commonly 
carried  on,  and  thus  the  virulent  Klebs-Loeffler  bacilli  separated  from 
those  non-virulent,  and  the  true  bacilli  from  the  pseudobacilli,  there 
would  be  a  more  earnest  desire  upon  the  part  of  physicians  at  large 
to  cooperate  with  health  boards  in  the  reporting  of  cases,  and  many 
cases  would  be  released  from  an  unnecessary  and  uselessly  prolonged 
c|uarantine.  In  considering  the  length  of  quarantine  it  is  well  to 
remember  that  diphtheria  bacilli  may  often  retain  their  virulence  for 
at  least  four  or  five  months  outside  the  human  body. 

The  nose  may  be  infected  through  the  anterior  nares.  These  are 
the  cases  where  the  infection  is  most  likely  to  be  limited  to  the  nose. 
Both  sides  are  more  often  involved  than  one  side  alone.  The  involve- 
ment of  the  sinuses  and  the  antrum  of  Highm.ore  may  explain  the 
persistence  and  the  difficulty  of  removal  of  the  bacilli  in  certain  nasal 
cases. 

Only  those  cases  are  called  nasal  diphtheria  that  show  an  involve- 


662  THE  SPECIFIC  INFECTIOUS  DISEASES 

ment  of  the  nose  alone.  It  does  not  include  cases  where  pharyngeal, 
tonsillar  or  laryngeal  diphtheria  is  present. 

Mild  cases  may  be  described  as  those  with  few  or  no  constitutional 
symptoms,  little  or  no  membrane,  very  little  nasal  discharge. 

In  moderate  cases  there  are  slight  'constitutional  symptoms  and 
persistent  and  often  copious  nasal  discharge,  which  may  be  purulent 
and  blood-streaked,  excoriating  the  upper  lip.  It  may  persist  for 
several  weeks  and  yet  the  child  be  in  apparently  very  good  health. 
Membrane  is  usually  present. 

In  severe  cases  the  nares  are  obstructed  and  the  child  breathes 
with  difficulty  through  the  nose,  the  mouth  is  kept  open,  respiration  is 
labored,  the  tongue  dry.  ]Membrane  can  be  easily  seen,  and  small  or 
profuse  nasal  hemorrhages  may  occur.  The  discharge  often  has  a 
decided  odor.  The  submaxillary  and  glands  at  the  angle  of  the  jaw 
are  swollen  and  a  distinct  toxemia  may  exist.  The  child  is  asthenic, 
the  pulse  is  rapid,  weak  and  perhaps  irregular;  there  is  stupor  and 
decided  anemia.  The  blood  shows  a  reduction  in  red  cells  and  of 
hemoglobin,  the  reduction  being  in  proportion  to  the  severity  of  the 
case.     There  is  usually  a  leukocytosis. 

The  temperature  is,  as  a  rule,  moderate — 100°  to  101.5°  F.  Albu- 
min is  usually  present  in  the  lu-ine  in  severe  cases.  Hyaline  and  granular 
casts  are  present,  but  not  in  large  numbers.  Dropsy  is  uncommon. 
Nausea,  vomiting  and  diarrhea  are  often  present.  A  moderate  degree 
of  delirium  is  quite  common.  The  membrane  disintegrates  slowly; 
it  may  be  dislodged  in  a  large  cast  or  mass  by  a  violent  sneeze. 

The  constitutional  disturbances  which  accompany  this  form  of 
diphtheria  may  be  more  severe  than  those  in  the  tonsillar  type. 
They  are  due  to  the  ease  with  which  toxins  are  absorbed  by  the  injured 
capillary  bloodvessels  at  the  seat  of  membrane  formation.  Nose- 
bleed occurs  even  in  the  mildest  types  of  the  disease,  and  becomes 
in  many  instances  extremely  annoying.  It  is  in  this  form  of  diphtheria 
that  postdiphtheritic  paralysis  is  most  apt  to  follow.  At  times  the 
disease  assmnes  a  chronic  form,  and  has  the  appearance  of  chronic 
rhinitis.  This  is  one  of  the  modes  in  which  infection  is  frequently 
conveyed  to  others,  the  individual  affected  being  totally  ignorant  of 
the  true  nature  of  the  discharge. 

The  local  and  constitutional  symptoms  lessen  rapidly  with  the 
disappearance  of  the  membrane.  The  anemia  and  evidences  of  a 
weak  heart  are  usually,  however,  slowly  recovered  from. 

The  membrane  which  appears  in  the  nose  in  most  cases  of  scarlet 
fever  and  measles  is  not  commonly  diphtheritic,  especially  if  it  occurs 
early  in  the  disease  or  during  the  height  of  the  disease.  Membrane 
occurring  in  the  later  stages  of  measles  or  scarlet  fever  is  often  diph- 
theria, and,  if  diphtheritic,  the  inflammation  of  the  surrounding 
mucous  membrane  is,  as  a  rule,  not  severe. 

As  a  diagnostic  aid  it  is  well  to  remember  that  the  membrane  in 
diphtheria  may  be  found  only  in  the  nose;  membrane  not  diphtheritic 
is  rarely  so  limited.     Albumin  in  the  urine  is  suggestive  of  diphtheria, 


Diphtheria  6G3 

but  if  the  case  is  a  mild  one,  and  no  toxemia  exists,  albuminuria  would, 
of  course,  not  be  expected  to  occur.  Paralysis,  especially  regurgitation 
of  liquids  from  the  nose,  would  be  in  favor  of  diphtheria. 

A  cover-glass  smear  will  often  enable  one  to  quickly  make  a  diagnosis, 
but  a  culture  is  more  accurate,  and  as  the  local  and  constitutional 
symptoms  are  usually  very  mild,  a  culture  is  much  to  be  preferred. 
Klebs-Loeffler  bacilli  may  disappear  early  in  the  disease,  and  may 
not  be  found  when  the  membrane  has  largely  disappeared.  If  mem- 
brane is  present  all  bacilli,  which  culturally  and  morphologically  are 
diphtheritic,  should,  in  my  opinion,  be  considered  true  diphtheria 
bacilli,  unless  proven  pseudodiphtheritic  by  inoculation  of  a  guinea-pig. 

Any  child  who  is  shown  to  have  diphtheria  bacilli  in  the  nose, 
even  if  it  presents  no  clinical  evidences  of  the  disease,  is  a  possible 
source  of  danger,  and  the  child  should  be  isolated  until  the  bacilli  are 
proven  to  be  non-virulent.  Children  exposed  to  diphtheria  are 
known  occasionally  to  have  the  bacilli  in  the  nose,  and  animal  inocula- 
tions prove  that  these  bacilli  may  be  virulent,  and  yet  these  children 
may  not  clinically  develop  diphtheria.  Children  in  bad  hygienic 
surroundings  and  in  institutions,  particularly,  show  this  tendency  to 
harbor  the  bacillus,  and  to  have  the  disease  develop  into  clinical 
diphtheria,  also  to  spread  it  to  other  children,  to  a  much  more 
marked  degree  than  where  the  conditions  from  a  hj^gienic  stand- 
point are  first-class. 

In  a  doubtful  case,  especially  if  the  child  has  been  exposed  to  diph- 
theria, and  a  nasal  discharge  persists,  a  single  negative  culture  is  not 
positive  proof  that  the  case  is  not  diphtheritic. 

An  interesting  question,  and  one  which  requires  much  careful 
future  study,  is  the  report  of  return  cases.  I  believe  that  future 
investigation  will  conclusively  prove  that  return  cases  occur  in  a 
greater  proportion  of  instances  than  is  now  believed,  and  I  do  not 
approve  of  the  doctrine  that  a  child  discharged  from  quarantine  with 
diphtheria  bacilli  in  the  nose,  who  is  clinically  free  from  diphtheria,  is, 
as  is  claimed  by  some  careful  observers,  not  able  to  transmit  the 
disease.  In  fact,  one  hears  continually  from  physicians  abuse  of 
health  boards  because  two  successive  negative  cultures  must  be 
obtained  before  the  child  is  allowed  out  of  quarantine.  What  is  the 
risk  incurred  by  children  who  come  in  contact  with  this  child  who  has 
been  clinically  free  from  diphtheria  for  some  days,  and  who,  neverthe- 
less, has  Klebs-Loeffler  bacilli  present  in  the  nose?  Is  one  warranted 
in  sending  these  cases  out  of  private  homes  and  hospitals  without 
inoculating  a  guinea-pig  to  test  the  virulence  of  the  bacilli?  Return 
cases  to  hospitals  do  not  show  a  very  large  percentage  of  infections 
from  such  patients.  C.  B.  Ker,  of  Edinburgh,  states  that  "Dr. 
Cameron  found  that  1.2  per  cent;  of  the  total  diphtheria  cases  were, 
after  their  discharge  from  hospital,  supposed  to  have  infected  persons 
with  diphtheria." 

It  is  an  interesting  point,  and  one  well  worthy  of  discussion,  as  to 
how  many  of  these  return  cases  are  real  infections  from  the  discharged 


664  THE  SPECIFIC  INFECTIOUS  DISEASES 

case,  and  how  many  are  cases  of  coincidence;  by  that,  I  mean,  happened 
to  contract  diphtheria  at  this  special  time  from  a  source  other  than  the 
discharged  patient,  but  contracted  it  just  at  the  time  when  it  would 
appear  that  infection  had  occurred  from,  the  discharged  case.  It  not 
uncommonly  happens  that  a  second  child  from  a  family  is  admitted 
to  the  hospital  a  few  days  before  the  first  child  is  returned  home. 
If  this  second  child  had  entered  the  hospital  a  few  days  after,  instead 
of  a  few  days  before  the  first  child  was  returned  home,  it  would  have 
been  classed  as  a  return  case.  However,  there  is  no  doubt  in  my 
mind  but  that  all  such  cases  with  diphtheria  bacilli  in  the  nose,  all 
clinical  evidences  of  the  disease  having  disappeared,  are  possible 
sources  of  danger. 

Every  suspected  case  of  nasal  diphtheria  should  be  quarantined 
and  isolation  continued  until  a  bacteriological  examination  proves 
the  case  to  be  non-diphtheritic.  Cultures  should  be  taken  from  all 
exposed  children;  and  those  showing  diphtheria  bacilli  should  be 
isolated  and  the  nose  and  throat  appropriately  treated. 

In  nasal  diphtheria  the  bacteria  may  show  an  unusual  tendency 
to  persist,  and  it  is  believed  this  may  be  due  to  the  nasal  sinuses  and 
antrum  being  involved.  The  danger  of  harboring  virulent  bacilli  in 
these  cases  of  long  standing  is  not  very  great;  the  bacilli  are  usually 
few^  in  number,  and  experience  proves  that  the  risk  of  contagion 
is  comparatively  slight.  It  is  unwise  to  admit  into  a  hospital  ward  or 
institution  any  child  who  shows  a  membrane  in  the  nose  or  has  a  nasal 
discharge,  unless  a  bacteriological  examination  has  shown  the  absence 
of  diphtheria  bacilli ;  and  all  children  in  hospitals  or  institutions  should 
be  carefully  watched  for  the  development  of  such  symptoms.  It  has 
been  the  experience  of  almost  all  physicians  with  hospital  experience 
to  see  epidemics  of  diphtheria  in  hospitals  originate  from  such  cases. 
The  number  of  visiting  days  and  the  number  of  visitors  to  children's 
wards  should  be  limited  as  far  as  possible,  and  no  children  should  ever 
be  admitted  as  visitors.  All  visitors,  and,  in  fact,  all  persons  entering 
a  children's  ward  should  wear  a  sterilized  cap  and  gown.  Such  a 
rule  has  been  inaugurated  at  the  Jefi^erson  Hospital,  and,  I  believe,  is 
of  decided  aid  in  preventing  outbreaks  of  the  disease. 

If  the  discharge  is  small  in  amount  and  there  are  no  constitutional 
symptoms,  it  is  unnecessary  to  irrigate  the  nose.  In  those  cases 
where  the  discharge  is  abundant  and  the  nasopharynx  is  more  or  less 
blocked  with  secretions,  it  is  important  to  keep  the  nose  and  naso- 
pharynx cleansed  with  warm,  mild  antiseptic  solutions.  Normal  salt 
solution,  weak  boric  acid  solution,  3  grains  to  the  ounce,  or  borate 
and  bicarbonate  of  soda,  5  grains  of  each  to  the  ounce,  may  be  used. 
All  solutions  should  be  used  warm;  no  unnecessary  force  should  be 
exerted,  and  the  child  should  always  be  firmly  wrapped  from  head  to 
foot  in  a  blanket.  As  the  treatment  is  designed  especially  to  wash 
out  the  nasopharynx,  the  fluid  entering  a  nostril  should  escape  from 
the  opposite  nostril  and  the  mouth.  A  fountain  syringe,  in  my 
opinion,  is  better  than  a  piston  syringe.     Enough  fluid  should  be  used 


DIPHTHERIA  665 

to  at  least  fairly  well  cleanse  the  nose  and  nasopharynx.  It  is  rarely 
necessary  to  employ  irrigation  oftener  than  once  in  four  hours.  Nasal 
hemorrhage  calls  for  great  care  in  the  use  of  the  syringe,  and  unless 
the  case  urgently  demands  syringing,  it  is  better  to  discontinue  it, 
if  hemorrhage  has  occurred. 

Antitoxin  should  certainly  be  given  in  every  case  of  nasal  diph- 
theria, and,  of  course,  the  earlier  it  is  given,  the  better  the  result  will 
be.  In  an  infant  it  is  dangerous  to  wait  until  a  diagnosis  can  be 
confirmed  by  a  bacteriological  examination.  In  older  children  with 
only  slight  nasal  discharge  and  no  toxemia  one  may  postpone  giving 
antitoxin  until  the  bacteriological  examination  confirms  the  diagnosis. 
To  postpone  the  early  use  of  antitoxin  in  a  case  of  profuse  nasal  dis- 
charge, with  membrane  present,  is,  in  my  opinion,  utterly  inexcus- 
able. 

Laryngeal  Diphtheria  or  Membranous  Croup. — This  may  either 
appear  as  true  diphtheria  or  may  be  diphtheroid  in  character.  In  the 
true  form  there  is  a  pseudomembranous  exudation  into  the  larynx 
and  trachea  which  results  in  croup.  The  cause  in  this  type  is  the  same 
as  in  other  types  of  true  diphtheria,  namely,  the  Klebs-Loeffler  bacillus. 
In  the  diphtheroid  type  the  pseudomembrane  formed  is  the  result  of 
invasion  by  bacteria  other  than  the  diphtheria  bacillus,  chiefly 
streptococci,  and  occasionally  staphylococci. 

It  has  become  the  custom  to  treat  all  cases  of  membranous  croup 
as  diphtheria,  even  though  it  is  conceded  that  other  organisms  than 
diphtheria  bacilli  may  be  the  factors  in  pseudomembranous  produc- 
tions. In  this  type  of  the  disease  there  is  often  little  or  no  involvement 
of  either  the  tonsils  or  the  fauces,  though  the  affection  is  belie;Ved  in 
most  instances  to  be  the  result  of  dow^nward  extension  from  these 
parts.  Not  infrequently  cases  are  seen  in  which  the  disease  is  confined 
solely  to  the  larynx.  It  is  in  this  type  that  the  exudate  may  extend 
into  the  trachea  and  bronchial  tubes. 

In  both  the  true  and  false  types  the  symptoms  closely  resemble 
each  other,  beginning  with  hoarseness,  slight  at  first,  and  with  a 
cough,  rough  in  character,  to  which  the  name  of  croup  is  given,  and 
which  lasts  for  a  period  of  one  or  two  days.  Suddenly  these  symptoms 
become  intensified  and  the  breathing  paroxysmal  as  a  result  of  spasm 
of  the  glottis.  Dyspnea  develops,  inspiration  is  accompanied  by 
retraction  of  the  lower  intercostal  spaces  and  the  epigastrium,  and 
expiration  is  difficult. 

The  skin  becomes  livid,  owing  to  im.perfect  oxygenation  of  the  blood, 
restlessness  is  extreme,  and  an  anxious  expression  due  to  fear  of 
suffocation  appears  on  the  face,  a  condition  which,  once  seen,  is  not 
soon  forgotten.  The  fever  is  usually  moderate  throughout  the  course 
of  the  disease  and  attracts  little  or  no  attention.  The  pulse  is  rapid, 
and  varies  in  frequency  from  120  to  200.  Usually  in  true  membranous 
croup  there  is  little,  if  any,  amelioration  of  the  symptoms  during  the 
daytime,  such  as  often  occurs  in  simple  croup.  Cough  is  paroxysmal 
in  these  cases,  and  membranous  casts  are  frequently  expelled. 


666  The  specific  •infectious  diseases 

In  laryngeal  diphtheria  the  early  symptoms  are  vague,  and  are  apt 
to  be  overlooked  unless  one  is  ever  mindful  of  the  possibility  of  diph- 
theritic involvement  of  the  larynx.  A  little  hoarseness,  a  croupy 
cough,  and  slight  inspiratory  dyspnea,  as  shown  by  recession  of  the 
suprasternal  notch,  supraclavicular  spaces,  and  epigastrium  are  noted 
early  in  the  case.  These  s^Tuptoms  are  progressive,  and  within  six 
to  twenty-four  hours  the  disease  is  often  fully  developed. 

The  voice  becomes  hoarse,  husky,  and  finally  lost.  The  dyspnea 
becomes  more  and  more  pronounced,  the  inspiratory  stridor  gradu- 
ally and  continuously  increases,  the  pulse  becomes  rapid,  the  face 
tiu'ns  pale  and  is  anxious,  the  aloe  of  the  nose  dilate  with  each  inspira- 
tion, the  child  is  restless,  perhaps  pulls  at  its  throat,  and  puts  its 
fingers  into  its  mouth.  AH  the  accessory  muscles  of  respiration  are 
brought  into  action. 

Gradually  the  child  becomes  weaker,  drowsy,  and  heavy.  Cyanosis 
of  the  lips  and  finger-nails  develops;  the  skin  is  cold  and  covered  with 
a  clammy  sweat.  Since  little  air  enters  the  lungs  owing  to  the  occlusion 
of  the  larynx  with  membrane,  we  hear  very. little  vesicular  murmur 
on  auscultation. 

Early  in  the  disease  the  temperatiue  is  not  higher  than  100°  or  101° 
F.;  but  as  symptoms  of  suffocation  increase,  the  fever  rises  to  103° 
or  104°  F.  The  child  becomes  more  and  more  quiet,  it  ceases  to 
struggle,  and  in  infants  death  may  ensue  in  thirty-six  to  sixty  hours 
after  the  development  of  the  disease.  Older  children  usually  live 
three  to  five  or  six  days. 

Improvement  in  the  symptoms  usually  occurs  in  those  cases  in 
which  the  false  membrane  is  expelled  in  whole  or  in  part  from  the 
lar^'iix  by  a  violent  paroxysm  of  coughing  or  vomiting.  Usually, 
however,  the  membrane  quickly  reforms,  and  the  symptoms  return. 

In  membranous  croup,  the  result  of  invasion  by  bacteria  other 
than  the  diphtheria  bacillus,  the  onset  is  not  so  sudden,  but  the  fever 
is  usually  high,  and  frequently  there  is  involvement  of  the  glands  of 
the  neck.  Often  a  false  membrane  forms  on  the  tonsils  or  fauces. 
In  this  type  of  the  disease  a  culture  taken  from  the  membrane  is  the 
only  method  of  determining  the  infecting  organism. 

The  mild  constitutional  symptoms  which  accompany  the  laryngeal 
t}T)e  may  be  accounted  for  by  the  fact  that  the  lymphatic  supply 
to  the  trachea  and  larynx  is  extremely  small.  The  chief  complication 
is  bronchopneumonia,  either  the  result  of  membrane  extension  into 
the  bronchial  tubes  or  inability  to  expel  the  mucopurulent  material 
from  the  tubes. 

Other  yarts  which  may  become  involved  are: 

1.  Middle  Ear. — By  extension  of  the  exudate  through  the  Eustachian 
tube  the  middle  ear  may  become  involved,  this  resulting  in  acute  otitis 
media.  The  t^TQpanic  membrane  ruptures  and  suppuration  takes 
place,  the  pus  containing  the  bacillus  of  diphtheria  together  with  other 
organisms.  Although  this  is  of  rare  occurrence,  yet  it  is  a  possibility, 
and  may  produce  temporary  deafness.     In  some  instances  the  deafness 


DIPHTHERIA  667 

may  be  permanent,  this  depending  upon  the  extent  to  which  the 
tjTiipanic  cavity  is  affected. 

2.  The  Eyes. — These  may  be  involved,  either  primarily  or  secondarily. 
Conjunctival  diphtheria  is  rare,  but  when  it  occurs  the  membrane 
spreads  rapidly  from  one  eyelid  to  the  other,  and  there  is  an  associated 
chemosis  of  the  bulbar  conjunctiva.  There  Ls  also  a  severe  form  of 
diphtheritic  ophthalmia  in  which  the  cornea  is  perforated,  and  destruc- 
tion of  the  eye  often  follows.  In  the  milder  form  there  is  simply  a 
slight  seropurulent  discharge. 

3.  The  Skin. — The  skin  surrounding  wounds  and  abrasions  may 
become  involved,  and  a  membrane  form  over  the  wound  or  around  it. 
This  is  most  frequently  seen  about  the  mouth  and  lips  as  the  result  of 
extension  in  cases  of  pharyngeal  diphtheria.  When  it  occurs  the 
diphtheria  bacillus  may  be  found  in  the  exudate. 

Diphtheritic  processes  have  also  been  observed  in  the  trachea  and 
bronchi,  in  the  stomach;  and  on  the  genitalia.  Wounds  made  by 
tracheotomy  and  circumcision  are  occasionally  infected  by  the 
Klebs-Loeffler  bacillus,  and  in  the  newborn  the  umbilicus  may  be 
involved. 

Septic  Diphtheria. — During  the  course  of  diphtheria  a  septic  condi- 
tion frequently  arises  which  is  the  result  of  infection  by  other  associated 
organisms;  namely,  streptococci  and  staphylococci.  This  type  of 
infection  is  most  apt  to  be  seen  in  the  nasal  form  of  the  disease  with 
associated  diphtheria  of  the  fauces,  the  exudate  showing  every  evidence 
of  decomposition,  and  resulting  in  a  fetid  discharge  from  the  mouth  and 
nose.  This  process  is  often  followed  by  ulceration  of  the  nasal  mucous 
membrane  with  resultant  hemorrhage.  The  lymphatic  glands  of  the 
neck  rapidly  become  involved,  are  swollen  and  tender,  and  may 
eventually  suppurate.  In  this  type  of  diphtheria,  in  addition  to  high 
fever  and  a  rapid  pulse,  there  is  frequently  a  rash  over  the  skin,  at 
first  erythematous,  and  later  becoming  petechial. 

Other  Symptoms  of  Diphtheria  which  Call  for  Special  Attention. — 1. 
Fever. — There  is  almost  invariably  fever  at  the  beginning  of  the  attack. 
It  varies  in  intensity  according  to  the  virulence  of  the  infection,  and 
usually  ranges  from  100°  to  102°  F.  during  the  first  forty-eight  hours 
of  the  disease,  falling  to  normal  two  or  three  days  after  the  exudate 
makes  its  appearance.  Should  the  temperature  remain  high  through- 
out the  course  of  the  disease,  it  should  suggest  the  existence  of  such 
complications  as  adenitis  and  suppuration.  In  laryngeal  diphtheria 
the  temperature  is  high  in  the  terminal  stage. 

2.  Disturhances  of  the  Circulation. — Yery  notable  in  diphtheria  is 
the  rapid  pulse  rate,  which  is  out  of  proportion  to  the  degree  of  tem- 
perature.    The  heart  sounds  become  distant  and  weak. 

3.  Nervous  Disturhances. — In  children  convulsions  may  usher  in 
the  disease.  They  are  most  often  seen  in  children  who  are  delicate 
and  of  a  nervous  temperament.  Delirium,  though  usually  mild, 
may  be  seen  in  any  of  the  forms  of  the  disease.  Occasionally  there 
is  perversion  of  the  senses  of  taste  and  smell. 


668  THE  SPECIFIC  INFECTIOUS  DISEASES 

Morbid  Anatomy. — Lymphatic  System. — The  cervical  lymphatics  are 
most  frequently  affected.  There  is  marked  leukocytic  infiltration 
together  with  minute  hemorrhages,  which  ultimately  result  in  resolution 
or  suppuration. 

Spleen. — This  organ  becomes  congested  and  swollen.  The  splenic 
tissue  is  soft,  and  degeneration  of  the  cells  is  almost  always  present, 
together  with  enlargement  of  the  follicles.  Infracapsular  hemorrhage 
is  of  common  occurrence. 

Liver. — Degeneration  and  necrosis  of  the  hepatic  cells  and  leukocytic 
infiltration  of  these  areas  are  frequently  observed. 

Kidneys. — As  a  result  of  the  toxins  circulating  in  the  blood,  degen- 
eration of  the  epithelial  lining  of  the  uriniferous  tubules  occurs,  and  in 
the  severe  types  of  the  disease  a  diffuse  nephritis  may  be  seen. 

Heart. — Myocarditis,  particularly,  of  the  left  ventricle,  is  apt  to 
appear  and  is  of  varying  intensity,  according  to  the  diu-ation  and 
severity  of  the  infection.  Cardiac  thrombi  account  for  a  certain 
percentage  of  sudden  deaths,  and  also  result  in  the  production  of  emboli 
in  the  lungs,  viscera,  and  arteries  of  the  extremities. 

Arteries. — Hyaline  degeneration  of  the  visceral  arteries,  infiltration 
of  the  adventitia,  and  degeneration  of  the  endothelial  layer,  are  the 
processes  most  likely  to  take  place. 

Blood. — Reduction  in  both  hemoglobin  and  the  number  of  red  cells 
occurs  in  practically  all  severe  cases  of  the  disease.  There  is  usually 
leukocytosis,  though  this  may  be  wanting. 

Nervous  System. — The  brain  may  be  the  seat  of  both  hemorrhages 
and  embolism,  and  the  spinal  cord  reveals  evidences  of  hemorrhage. 
The  cord  itself  is  apt  to  show  degeneration  of  the  ganglion  cells  of  the 
anterior  horns  of  the  anterior  and  posterior  nerve  roots,  also  at  times 
of  the  columns  of  Goll  and  the  pyramidal  tracts.  In  cases  of  mild 
diphtheritic  paralysis  the  lesions  found  are  usually  peripheral.  Certain 
nerves,  such  as  the  spinal  accessory,  hypoglossal,  pneumogastric, 
oculomotor,  and  cardiac  nerves  may  show  changes  of  degenerative 
tyjie  as  the  result  of  the  toxin,  and  when  so  affected  produce  lesions 
common  to  the  disease,  namely,  multiple  neuritis. 

Lungs. — Bronchopneumonia  is  frequently  found,  and  in  a  great 
number  of  instances  is  the  responsible  factor  in  causing  death.  It  is 
usually  the  result  of  the  aspiration  of  particles  of  membrane  from 
the  air  passages,  these  containing  streptococci  and  diphtheria  organ- 
isms. Emphysema,  when  found,  accompanies  the  laryngeal  type, 
and,  depending  upon  the  duration  of  the  illness,  may  be  either  vesicular 
or  interstitial. 

Complications  and  Sequelae. — Hemorrhage  may  result  from  ulceration 
of  either  the  nose  or  the  throat,  but  is  usually  of  minor  importance. 

Kidneys. — Nephritis  is  one  of  the  most  frequent  complications,  and 
is  seen  earlier  in  this  disease  than  in  scarlet  fever,  although  its  course 
is  somewhat  similar.  In  practically  every  instance  of  the  disease 
albuminuria  appears  from  the  second  to  the  fourth  day,  though  the 
amount  of  urine  may  not  be  altered;  in  fact,  the  quantity  is  often 


DIPHTHERIA  669 

increased.  When  nephritis  does  develop  it  is  the  result  of  injury 
to  the  parenchymatous  tissue  by  the  toxins  during  their  elimination. 
This  will  show  its  presence  by  the  appearance  of  casts,  both  epithelial 
and  blood,  and  occasionally  hyaline  and  granular.  The  amount  of 
urine  becomes  scanty,  and  at  times  there  is  suppression. 

Lungs. — In  laryngotracheal  diphtheria  the  lungs  frequently  become 
the  seat  of  bronchopneumonia,  whereas  in  faucial  diphtheria  simple 
bronchitis  is  more  apt  to  ensue.  Lobar  pneumonia  may  occur  during 
convalescence,  and  the  same  may  be  said  of  pleurisy. 

Heart. — It  has  been  stated  by  Jacobi  that,  no  matter  how  mild  the 
case  may  be,  the  heart's  function  becomes  affected  to  a  certain  extent. 
Endocarditis  and  myocarditis  are  both  the  result  of  the  action  of  the 
toxins  circulating  in  the  blood.  Heart  paralysis  occurs  with  greatest 
frequency  in  the  severe  forms  of  diphtheria  in  which  the  child  is 
apathetic,  and  shows  evidences  of  extreme  prostration.  These 
evidences  of  heart  failure,  when  seen,  usually  manifest  themselves  at 
the  height  of  the  disease,  which  is  usually  about  the  seventh  day.  This 
failure  may  result  from  paralysis  of  the  cardiac  nerves  without  any 
change  in  the  heart  muscle.  The  symptoms  of  heart  failure  are 
frequently  preceded  by  vomiting.  There  then  occur  cyanosis  and 
rapid  pulse,  which  later  becomes  slow  and  dicrotic,  and  the  muscular 
sounds  are  indistinct.  The  extremities  become  chilled  as  a  result  of 
the  failing  circulation,  though  the  mind  is  often  clear  until  death. 

All  this  may  occur  at  any  time  during  the  stage  of  convalescence, 
often  as  late  as  the  sixth  or  seventh  week,  and  the  child  may  have 
several  attacks  before  one  proves  fatal.  In  other  cases,  sudden  death 
may  occur  during  convalescence  from  cardiac  failure  when  there  have 
been  no  preceding  cardiac  symptoms.  Cardiac  irregularity  is  common 
in  children  during  convalescence,  but  does  not  necessarily  prove  fatal, 
and  may  disappear  in  the  course  of  several  weeks.  Both  measles 
and  scarlet  fever  may  complicate  diphtheria,  the  reason  being  difficult 
to  explain.  When  complicated  by  the  former,  the  disease  is  apt  to 
be  more  severe  because  of  the  changes  in  the  mucous  membranes 
produced  by  measles. 

Diphtheria  may  also  be  a  serious  complication  of  pertussis,  frequently 
causing  bronchopneumonia.  When  it  occurs  during  the  course  of 
typhoid  fever  or  in  tuberculous  children  it  usually  proves  fatal. 

Paralysis. — This  is  the  most  important  of  the  sequelae,  and  occurs 
after  the  acute  stage  of  the  disease,  most  often  during  convalescence. 
The  exact  cause  is  not  definitely  known,  but  it  is  regarded  as  a  toxic 
neuritis  which  affects  the  peripheral  nerves.  Most  frequently  it 
involves  the  palate,  this  resulting  in  nasal  speech  and  the  passage  of 
food  through  the  nose  instead  of  into  the  stomach.  There  may  also 
be  anesthesia  of  the  mucous  membrane  of  the  pharynx.  The  muscles 
of  deglutition  are  the  next  in  point  of  frequency  to  be  involved,  and 
then  the  eye  muscles,  chiefly  those  concerned  in  accommodation.  At 
times  strabismus  and  ptosis  may  be  seen,  more  rarely  facial  paralysis. 
There  may  be  paralysis  of  the  lower  extremities,  from  which  complete 


670  THE  SPECIFIC  INFECTIOUS  DISEASES 

recovery  seldom  occurs.  Respiratory  and  cardiac  paralysis  may 
occur  at  any  time  during  the  stage  of  convalescence,  and  result  in 
sudden  stoppage  of  the  heart's  action  and  cessation  of  respiration. 

There  may  be  no  preliminary  symptoms,  even  in  severe  forms  of 
cardiac  paralysis.  In  other  cases  there  may  have  been  preceding 
cardiac  irregularity,  and  often  there  is  slight  albuminuria.  In  many 
instances,  the  child  is  apparently  in  good  health,  when  suddenly  there 
is  abdominal  pain,  dyspnea,  cyanosis  of  the  lips,  slow,  thready  pulse 
with  weak,  scarcely  audible,  heart  action,  and  coolness  of  the  extrem- 
ities. Not  infrequently  a  child  will  survive  one  or  two  of  these  attacks 
only  to  succumb  finally. 

G astro-enteritis. — Disturbances  of  the  gastro-intestinal  tract  are 
dangerous,  and  not  uncommon,  complications  of  diphtheria  in  infants. 
The  diarrhea  may  become  very  severe,  and  in  rare  instances  death  has 
resulted  from  extension  of  the  membrane  into  the  esophagus,  stomach, 
and  intestine. 

Diagnosis. — The  disease  may  be  diagnosed  both  clinically  and 
bacteriologically,  though  ofttimes  the  diphtheria  organisms  may  be 
found  in  the  throats  of  healthy  individuals  without  any  symptoms  of 
the  disease,  consequently  their  mere  presence  does  not  constitute  a 
diagnosis  of  diphtheria.  Nevertheless,  when  they  are  present  together 
with  certain  clinical  evidences  the  diagnosis  is  complete.  In  a  great 
number  of  instances  the  diagnosis  is  to  be  made  from  the  clinical 
evidences  alone,  especially  in  cases  where  the  exudate  is  rapidly  spread- 
ing. In  the  milder  atypical  forms  it  frequently  becomes  necessary 
to  determine  by  culture  the  presence  or  absence  of  diphtheria  organisms 
in  order  to  make  a  diagnosis  and  protect  other  members  of  the  family. 

Clinically,  the  following  factors  ought  to  be  of  some  help  in  making 
a  diagnosis.  The  presence  of  a  fiocculent  nasal  discharge  which  later 
becomes  blood-tinged,  enlargement  of  the  cervical  lymphatic  glands, 
the  early  appearance  of  croup,  which  becomes  progressively  worse, 
the  presence  of  a  grayish  patch  on  the  tonsils  which  rapidly  spreads, 
at  times  over  the  soft  palate  and  the  uvula,  are  very  significant  of 
diphtheria. 

In  instances  where  diphtheria  is  associated  with  scarlet  fever  or 
measles  the  variations  may  be  so  marked  as  to  make  diagnosis  difficult. 
In  cases  of  pseudodiphtheria  the  onset  is,  as  a  rule,  rapid,  the  consti- 
tutional symptoms  are  marked,  and  there  is  a  decided  elevation  in 
temperature.  It  rarely  begins  primarily  in  the  larynx  and  only  in 
extremely  few  instances  is  albuminuria  an  early  symptom.  The 
mucous  membranes  in  pseudodiphtheria  become  exceedingly  inflamed 
and  the  exudate  present  is  easily  removed  by  the  use  of  a  swab. 

A  diagnosis  of  the  unusual  types  of  the  disease  may  be  made  by  a 
bacteriological  examination.  The  following  is  the  method  used  by  the 
Philadelphia  Board  of  Health:  Physicians  can  obtain  from  the  various 
police  stations  envelopes  containing  two  tubes.  One  tube  contains 
two  small  wires;  at  one  end  of  each  wire  a  small  amount  of  cotton 
is  attached.     The  other  tube  contains  the  necessarv  culture  medium 


DIPHTHERIA  671 

which  is  inoculated  by  rubbing  the  swab  over  any  exudate  present,  and 
then  gently  passing  it  over  the  surface  of  the  culture  medium.  The 
cotton  stopper  is  replaced  in  the  culture  tube,  the  swabs  are  placed 
in  their  original  tube,  and  both  tubes  are  returned  to  the  police  station. 
They  are  then  sent  to  the  Laboratory  of  the  Bureau  of  Health,  where  the 
tube  containing  the  culture  medium  is  incubated  for  a  definite  length 
of  time,  and  then  examined  microscopically.  The  physician  is  notified 
by  telephone  whether  or  not  any  diphtheria  organisms  were  found 
on  the  mediurn.  Just  prior  to  taking  a  culture  no  antiseptics  should 
be  used  upon  the  throat,  and  great  care  should  be  exercised  not  to 
contaminate  the  culture  medium  with  other  organisms  than  those 
from  the  exudate.  Sometimes  we  obtain  a  negative  culture  from  a 
case  of  diphtheria  which  presents  all  the  clinical  evidences  of  the 
disease;  again,  we  may  obtain  a  positive  culture  from  the  throat  of 
an  individual  who  clinically  has  not  the  disease.  In  all  cases,  when 
clinical  evidences  are  present,  a  positive  culture  constitutes  a  positive 
diagnosis. 

The  conditions  with  which  this  disease  is  most  apt  to  be  confused 
are  the  various  forms  of  diphtheroid  faucitis  and  the  faucitis  of  scarlet 
fever. 

Follicular  Tonsillitis. — This  disease  is  more  often  mistaken  for 
diphtheria  than  any  other  throat  affection.  The  exudate  in  this  type 
does  not  show  a  tendency  to  spread  and  usually  affects  the  tonsil  crypts. 
It  is  easily  detached,  and  when  crushed  gives  off  an  extremely  fetid 
odor.  The  constitutional  symptoms  are  often  intense.  There  are 
high  fever,  headache,  chills,  pains  in  the  back  and  extremities.  The 
throat  is  sore,  sw^allowing  becomes  difficult,  and  there  is  tenderness 
about  the  neck  at  the  angle  of  the  jaw.  Sometimes  the  disease  may 
closely  simulate  mild  diphtheria,  and  in  such  instances  a  bacteriological 
culture  may  be  necessary  to  determine  its  true  nature. 

Scarlet  Fever. — The  absence  of  eruption  is  a  great  aid  in  making 
the  diagnosis,  although  the  eruption  in  scarlet  fever  may  be  wanting 
or  extremely  mild,  and  an  erythematous-  blush  may  accompany 
diphtheria.  In  such  instances  a  history  of  exposure  or  the  prevalence 
of  an  epidemic  should  form  a  clue.  Of  course,,  when  desquama- 
tion occurs  the  question  is  readily  settled,  but  often,  as  in  follicular 
tonsillitis,  a  bacteriological  culture  is  necessary. 

In  scarlet  fever,  however,  the  redness  in  the  throat  is  much  more 
diffuse  than  in  diphtheria,  and  when  there  is  a  membrane  in  the 
throat  it  appears  to  be  embedded  in  the  tonsil  instead  of  upon  it,  as 
in  diphtheria.  Diphtheritic  membrane,  as  a  rule,  forms  late  in 
scarlet  fever,  early  membrane  formation  being  due  in  most  cases  to 
streptococcus  infection. 

Catarrhal  Croup. — During  the  early  stages  this  is  frequently  confused 
with  membranous  croup.  In  true  membranous  croup  there  is  no 
amelioration  of  symptoms  during  the  daytime,  but  they  become  pro- 
gressively worse,  the  hoarseness  more  intense,  the  breathing  more 
difficult.     Restlessness  and  cyanosis  appear,  and  the  typical  tugging 


672  THE  SPECIFIC  INFECTIOUS  DISEASES 

of  the  diaphragm  is  seen.  In  catarrhal  croup  an  emetic  frequently 
relieves  all  of  the  symptoms,  whereas  in  true  membranous  croup 
this  is  not  the  case  and  there  is  usually  no  exudate  in  the  fauces. 

Stomatitis. — In  severe  cases  of  this  disease  the  minute  ulcers  may 
coalesce  and  form  patches,  which  may  cause  confusion  in  diagnosis. 
The  exudation  in  such  instances  is  usually  thin  and  never  membranous, 
although  here  also  it  may  be  necessary  to  resort  to  bacteriological 
differentiation. 

Prognosis. — The  prognosis  should  always  be  guarded,  for  a  positive 
one  is  impossible. 

The  mildness  or  severity  of  the  attack  does  not  necessarily  have  any 
influence  on  the  prognosis  because  of  the  complications  which  may 
result  and  the  rapidity  with  which  the  membrane  frequently  extends. 
At  times  what  appears  to  be  a  very  mild  case  suddenly  becomes  an 
exceedingly  severe  one;  again,  cases  that  are  most  severe  in  the  begin- 
ning may  suddenly  change  for  the  better,  and  make  a  rapid  and 
uneventful  recovery. 

Much  depends  on  an  early  diagnosis,  and  the  giving  of  antitoxin 
immediately  upon  seeing  the  case,  if  the  local  or  constitutional  symp- 
toms are  severe.  If  the  case  is  a  mild  one,  we  may  wait  for  the  result 
of  the  culture ;  but  it  is  worse  than  foolish  to  do  so  in  severe  cases. 

In  uncomplicated  cases  in  which  antitoxin  is  given  on  the  first  day, 
the  mortality  is  almost  nil.  If  injected  on  the  second  day,  the  mor- 
tality is  not  more  than  2  per  cent.;  if  antitoxin  is  not  given  in  these 
uncomplicated  cases  until  the  third  day,  it  will  be  6  per  cent. ;  at  the 
fourth  day,  11  per  cent.;  and  after  this  period  much  higher. 

There  are  times  when  tiie  nature  of  the  epidemic  has  a  bearing  on 
the  prognosis.  In  some  epidemics  the  cases  are  all  exceedingly  mild, 
whereas  in  others  they  are  all  of  severe  type,  and  the  death-rate  is 
consequently  increased.  The  general  health  of  the  child  has  but 
little  influence  on  the  severity  of  the  attack  or  the  ultimate  result,  and 
the  social  status  of  an  individual  has  little  or  no  bearing  upon  the 
prognosis.  Frequently  children  in  families  whose  surroundings  are 
poor  show  better  recuperative  powers  than  those  who  have  all  the 
necessities  and  copiforts  of  life.  Of  course,  where  the  surroundings 
are  good,  and  everything  desirable,  the  care  of  the  patient  is  easily 
obtainable,  the  probability  of  recovery  is  naturally  greater,  and 
greater  still  are  the  chances  of  recovery  from  the  sequelae  of  the  disease. 

Number  of  Deaths  in  Philadelphia — Diphtheria. 


Age  period. 

1911. 

1912. 

1913. 

1914. 

1915 

Under  1 

year 

.      .        33 

26 

22 

19 

24 

1  to    2 

years 

.      .       93 

77     ■ 

87 

72 

70 

2  to    5 

" 

.      .      229 

163 

152 

141 

119 

5  to  10 

" 

. .      .      100 

79 

79 

70 

68 

10  to  15 

" 

.       .        10 

12 

8 

9 

10 

15  to  20 

" 

.      .          2 

5 

1 

1 

4 

All  ages 

.      .      481 

388 

361 

323 

188 

The  mortality  in  children  under  five  years  of  age  is  greater  than 
at  anv  other  time  of  life.     Infants  and  very  young  children  frequently 


DIPHTHERIA  673 

succumb  to  laryngeal  diphtheria,  and  at  all  ages  diphtheria  of  the 
posterior  nares  and  nasopharynx  is  the  most  rapidly  fatal  type,  death 
being  caused  by  toxemia.  Diphtheria  of  the  anterior  nares  is  usually 
very  mild;  but  mixed  infection  in  diphtheria  render  the  prognosis 
grave. 

Other  conditions  being  equal,  the  extent  of  the  membrane  is  an 
indication  of  the  severity  of  the  attack.  Malignant  and  septic  cases 
are  often  fatal.  The  presence  or  absence  of  complications  also  influ- 
ences the  prognosis  to  a  certain  extent;  thus,  hemorrhage,  acute 
nephritis,  or  the  involvement  of  other  organs  is  of  serious  import. 

Postdiphtheritic  paralysis  develops  as  frequently  in  strong  children 
as  in  weaklings,  and  the  outlook  in  these  cases  depends  upon  the 
condition  of  the  heart  and  respiratory  muscles.  Scrofulous  children 
and  those  suffering  from  other  constitutional  dyscrasise  usually 
succumb.  Mot-e  male  children  are  affected  than  females,  but  this  is 
merely  due  to  the  fact  that  male  children  are  more  likely  to  be  exposed 
because  of  the  general  tendency  to  allow  them  to  play  about  the  streets, 
whereas  the  girls  are  kept  at  home.  Of  great  importance  in  prognosis 
is  the  question  whether  or  not  antitoxin  is  used  early  in  the  disease. 
In  some  cases  the  diagnosis  is  made  so  late  that  the  use  of  antitoxin  is 
of  little  benefit.  Yet  there  may  be  exceptions  to  this,  and  children 
who,  to  all  appearances,  were  not  likely  to  recover,  have,  especially 
after  an  intravenous  injection  of  antitoxin,  been  brought  back  from 
what  seemed  certain  death  to  complete  recovery. 

Prophylaxis. — Every  case  of  sore  throat  which  looks  at  all  suspicious 
should  be  promptly  isolated  from  other  members  of  the  family  until 
an  accurate  diagnosis  can  be  reached,  either  by  awaiting  clinical 
developments  or  by  a  bacteriological  culture.  Other  children  in  the 
family  should  be  prevented  from  attending  school  or  coming  in  contact 
with  children  outside  the  family  until  the  diagnosis  is  settled,  because 
of  the  fact  that  children  in  a  family  in  which  there  is  a  case  of  diph- 
theria often  have  diphtheria  organisms  in  their  throats  and,  if  allowed 
to  be  at  large,  may  possibly  convey  the  infection  to  others.  Should 
any  children  in  the  family  show  the  presence  of  diphtheria  organisms 
in  their  throats,  although  not  suffering  with  the  disease  clinically,  they 
should  be  isolated,  but  not  with  the  child  who  is  ill. 

The  sick-room  should  be,  preferably,  on  the  top  floor.  It  should 
have  the  sunniest  exposure,  and  all  hangings,  draperies,  and  unneces- 
sary furniture  should  be  removed  from  it.  A  sheet  should  be  hung 
at  the  door  and  kept  saturated  with  a  weak  solution  of  carbolic  acid, 
formalin,  or  a  solution  of  chloride  of  lime.  The  surfaces  of  the  rooms 
should  be  wiped  off  daily  with  a  bichloride  of  mercury  solution  1  to 
2000.  Eating  utensils  and  refuse  from  the  room  should  be  placed  in 
a  solution  of  carbolic  acid,  1  to  30,  and  allowed  to  remain  there  for  at 
least  an  hour  before  being  taken  out  of  the  room.  The  nurse  in 
attendance  should  remain  in  the  room,  and  not  come  in  contact  with 
other  members  of  the  family.  She  should  wear  a  long  gown,  that  can 
be  easily  disinfected,  to  cover  her  ordinary  dress,  and  a  cap  that  will 
43 


674  THE  SPECIFIC  INFECTIOUS  DISEASES 

cover  her  hair.  These  should  be  removed  upon  leaving  the  room, 
and  left  just  outside  where  they  can  be  readily  put  on  before  reentering. 
All  towels,  as  well  as  handkerchiefs  or  other  pieces  of  cloth  used  for 
cleansing  the  mouth  and  nose  of  the  patient,  should  be  immersed  in  a 
solution  of  chloride  of  lime  and  subsequently  burned. 

In  view  of  the  fact  that  diphtheria  organisms  remain  active  in  the 
throat  of  an  individual  who  has  suffered  from  the  disease,  often  for 
weeks  after  apparent  recovery,  the  child  should  be  kept  isolated  until 
two  negative  bacteriological  cultures  are  obtained  on  succeeding 
days,  provided  that  a  period  of  two  weeks  has  elapsed  from  the  onset 
of  the  illness.  After  two  such  cidtures  are  obtained  the  patient  should 
be  removed  to  another  room,  and  the  sick-room  thoroughly  disinfected. 
This  is  best  done  by  the  use  of  formaldehyde  gas.  When  the  above 
principles  of  isolation  and  quarantine  cannot  be  carried  into  effect  it 
is  wise  to  send  the  chUd,  if  possible,  to  a  hospital  for  the  treatment 
of  contagious  diseases.  In  this  manner  secondary  cases  are  prevented 
and  the  health  of  the  community  at  large  is  not  jeopardized. 

All  exposed  children  should  not  only  be  cultured,  as  previously 
stated,  but  should  also  receive  an  immunizing  dose  of  antitoxin, 
provided  they  are  not  asthmatic.  When  a  case  of  diphtheria  develops 
in  an  institution,  all  children  who  have  been  in  contact  ought  imme- 
diately to  be  cultured,  immunized,  and  isolated,  and  should  show  a 
negative  culture  prior  to  being  allowed  to  mingle  with  other  children, 
even  though  they  show  no  clinical  evidences  whatsoever  of  the  disease. 
The  dose  for  immunizing  is  from  100  to  1200  units,  depending  upon 
the  age  of  the  child.  Individuals  who  nurse  cases  of  diphtheria  should 
receive  a  dose  of  at  least  1200  units^ 

In  addition  to  immunization  with  antitoxin  it  is  also  advisable  for  all 
contacts  to  cleanse  the  nasopharynx  and  throat  three  times  a  day  with 
a  1  to  5  solution  of  liquor  alkalinus  antisepticus  or  Dobell's  solution. 
This  precaution  is  particularly  essential  in  those  cases  in  which  there 
are  contra-indications  to  the  administration  of  antitoxin. 

The  Schick  reaction,  which  has  lately  become  popular,  particularly 
in  institutional  work,  is  of  some  advantage  in  determining  the  sus- 
ceptibility of  different  children  to  the  disease,  thus  indicating  those 
to  whom  it  is  necessary  to  give  antitoxin.  The  method  of  obtaining 
this  reaction  is  as  follows: 

Following  the  observations  of  von  Behring,  Schick  determined  that 
if  the  serum  of  an  individual  contained  as  much  as  yw  o^  ^  unit  of 
antitoxin  per  cubic  centimeter  lie  possessed  a  sufficient  degree  of 
immunity.  He  further  demonstrated  that  when  an  amount  of  diph- 
theria toxin  equivalent  to  5^  of  a  minimal  lethal  dose  for  a  guinea- 
pig  weighing  from  250  to  300  grams  was  intracutaneously  injected, 
and  was  not  followed  by  a  reaction,  the  serum  of  the  individual 
contamed  -^  or  more  of  antitoxin  per  cubic  centimeter. 

Should  the  amount  of  antitoxin  present  be  less,  there  will  be  a  local 
inflammatory  reaction  at  the  site  of  injection,  due  to  the  fact  that 
the  toxin  injected  is  not  neutralized.     A  negative  reaction  indicates 


DIPHTHERIA  675 

that  the  individual  possesses  sufficient  immunity  against  the  disease, 
whereas  a  positive  reaction  indicates  that  he  is  still  susceptible  and 
therefore  should  receive  a  sufficient  amount  of  antitoxin  to  produce 
immunity.  Before  the  introduction  of  the  Schick  reaction  it  had  been 
our  custom  in  the  children's  ward  of  Jefferson  Hospital  to  test  for 
anaphylaxis  when  immunizing  by  first  giving  a  small  dose  of  antitoxin 
and  then  a  larger  one  if  no  untoward  symptoms  developed,  but  recently 
we  have  used  the  Schick  reaction  instead  of  the  small  dose  of  anti- 
toxin with,  perhaps,  more  accurate  results. 

Treatment. — The  treatment  of  diphtheria  has  been  properly  classified 
into  hygienic,  local,  constitutional,  and  with  antitoxin. 

Hygienic  Treatment. — The  room  occupied  by  the  patient  should 
be  free  from  all  carpets,  hangings,  and  unnecessary  furniture.  It 
should  1|e  well  ventilated,  and  the  temperature  kept  at  about  70°  F. 
A  room  with  an  open  fireplace  and  several  windows  is  most  desirable. 
The  nurse  should  be  the  only  one  to  occupy  the  room  beside  the  patient. 
The  physician  in  attendance  should  take  every  precaution  to  prevent 
the  spread  of  the  disease.  While  in  contact  he  should  wear  a  linen  gown 
with  a  hood  that  completely  covers  his  head.  Upon  leaving  the  room 
his  face  and  hands  should  be  thoroughly  washed  in  a  1  to  3,000  solution 
of  corrosive  sublimate.  Absolute  quarantine  should  be  enforced, 
so  as  to  prevent  the  possibility  of  infecting  other  members  of  the 
family. 

Local  Treatment. — In  view  of  the  fact  that  the  organisms  of  the 
disease  are  present  in  the  exudate  in  the  throat,  and  knowing  that  they 
continuously  multiply  and  produce  toxic  materials  which  are  respon- 
sible for  most  of  the  constitutional  symptoms,  it  is  the  belief  of  some 
clinicians  that  local  measures  should  be  resorted  to  that  will  tend 
to  prevent  the  multiplication  of  the  bacteria.  Numerous  drugs  have 
been  used  locally  for  some  time  past,  and  each  physician  has  his 
favorite  method  and  drugs  for  swabbing  the  throat.  Today  active 
cauterants  are  not  often  used,  but  reliance  is  placed  upon  antiseptics 
that  wull  cause  no  damage  to  the  tissues  w4th  which  they  come  in 
contact,  yet  have  destructive  effect  on  the  organisms  present.  Those 
most  frequently  used  are  potassium  permanganate,  1  to  5000,  car- 
bolic acid,  1  per  cent.,  subsulphate  of  iron,  potassium  chlorate,  and 
chloral  hydrate  or  glycoth}^moline,  25  per  cent,  solution. 

As  a  rule  these  drugs  are  applied  to  the  throat  by  means  of  a  swab, 
brush,  or  spray.  Another  drug  which  may  be  used  either  in  the  form 
of  a  dry  powder  or  a  liquid  is  the  salicylate  of  sodium.  In  young 
children  and  infants  it  is  often  extremely  difficult  to  employ  local 
treatment.  In  very  young  infants  solutions  can  be  dropped  into  the 
nostrils,  and  in  this  way  they  gain  access  to  the  fauces. 

The  opinion  regarding  local  measures  has  changed  considerably 
within  the  past  few  years,  and  today  the  idea  is  not  so  much  to  prevent 
further  multiplication  of  the  organisms  as  to  keep  the  nose,  mouth, 
and  pharynx  clean.  This  is  easily  appreciated  in  view  of  the  fact  that 
b^  so  doing  the  bacteria  are  to  some  extent  prevented  from  gaining 


676  THE  SPECIFIC  INFECTIOUS  DISEASES 

access  to  the  larynx  and  bronchial  tubes.  Absorption  of  toxins  is  also 
delayed,  and  further  toxemia  prevented.  Ordinary  salt  solution, 
Dobell's  solution,  or  a  saturated  solution  of  boric  acid  will  suffice. 
These  can  be  applied  either  with  an  atomizer  or  a  fountain  syringe. 
The  solution  should  be  warm  and  in  sufficient  quantity  thoroughly  to 
irrigate  the  parts  affected. 

For  hemorrhage  from  the  nose,  if  severe,  solutions  which  are  more 
or  less  astringent,  such  as  alum,  or  a  1  to  3000  solution  of  adrenalin 
chloride,  are  required.  The  number  of  douchings  necessary  depends 
upon  the  amount  of  discharge.  In  mild  cases  three  times  a  day  is 
usually  sufficient,  whereas,  in  the  severe  types  with  profuse  nasal  dis- 
charge, it  may  be  necessary  to  syringe  the  nose  every  third  hour.  For 
the  relief  of  pain  caused  by  the  cervical  adenitis,  an  ice-bag  may  be 
placed  on  the  neck,  or  a  25  per  cent,  ichthyol  ointment  appMed. 

Constitutional  Treatment. — ^The  child  should  remain  in  bed  through- 
out the  attack.  A  purgative  should  be  given  at  the  beginning  of  the 
disease,  preferably  calomel,  1  to  3  grains,  depending  upon  the  age  of 
the  child.  If  the  fever  is  high,  nothing  is  more  beneficial  than  tepid 
baths,  that  is,  at  98°  F.  The  use  of  such  drugs  as  the  coal-tar  products 
should  be  discouraged,  because  of  their  depressing  effect. 

The  diet  should  be  liquid,  consisting  chiefly  of  milk,  alternating  with 
broths.  Feeding  the  child  with  diphtheria  is  an  all-important,  but 
often  a  difficult  task,  since  the  appetite  may  be  completel}^  lost. 
The  nursling  must  be  taken  from  the  breast,  and  given  breast  milk 
from  a  bottle,  unless  there  is  diarrhea,  when  milk-feeding  should  be 
temporarily  suspended  until  impl-ovement  is  noted.  The  older  child 
should  be  given  broths,  beef  juice,  fruit  juices,  and  ice-cream  in  small 
quantities  at  frequent  intervals. 

Everything  possible  should  be  done  to  build  up  the  child's  powers 
of  resistance,  and  in  some  cases  1  to  2  drams  of  wine  may  be  given 
four  times  daily  with  beneficial  results.  Water  should  be  given 
freely. 

For  many  years  past  iron  has  been  used  internally  during  the  course 
of  the  disease  and  has  gained  in  favor  because  of  its  good  effects,  both 
generally  and  locally.  It  should  be  administered  in  fairly  large  doses 
and  at  frequent  intervals,  the  amount,  of  course,  depending  upon  the 
age  of  the  child.  Children  one  to  three  years  of  age  may  be  given 
10  drops  of  the  tincture  every  three  hours,  and  older  children  20  drops. 
An  excellent  method  of  administering  it  is  in  combination  with  gly- 
cerin. In  instances  where  marked  stimulation  is  necessary,  the 
tendency  today  is  to  omit  iron  for  a  time,  and  rely  upon  stimulants. 

Bichloride  of  mercury  is  another  drug  which  exerts  a  beneficial  effect, 
and  has  been  used  for  many  years.  It  is  frequently  combined  with  the 
tincture  of  ferric  chloride,  and  in  this  way  the  action  of  both  drugs 
is  obtained,  and  is  unquestionably  beneficial.  The  amount  of  bichlo- 
ride of  mercury  to  be  given  needs  some  consideration,  although  there 
are  few  instances  in  which  it  has  had  any  injurious  effect.  Jacobi 
states  that  a  child  one  year  old  may  be  given  \  grain  every  twenty- 


DIPHTHERIA  677 

four  hours  in  divided  doses  for  many  days  in  succession  without  any 
intestinal  disturbance. 

Another  drug  used  internally  is  calomel,  in  fractional  doses,  but 
because  of  its  constant  purgative  effect  it  has  lost  favor,  the  weakness 
produced  being  greater  than  the  benefit  derived,  save  when  given  as 
a  purgative  at  the  onset  of  the  disease.  Chlorate  of  potash,  because 
of  its  beneficial  influence  in  stomatitis,  has  been  extensively  used  in 
diphtheria;  but  because  of  the  injury  to  the  kidneys  when  given  in 
doses  large  enough  to  have  any  good  effect,  its  use  has  been  more  or 
less  discontinued. 

Caffein  citrate,  1  grain  every  three  hours;  strychnine,  2Tu  to  -oh) 
of  a  grain  hypodermically;  digitalis,  1  to  5  minims,  and  alcohol  are  all 
useful  in  combating  cardiac  depression,  especially  the  last,  in  view 
of  the  fact  that  there  are  few  cases  which  do  not  need  stimulation,  in  one 
way  or  another.  It  is  most  frequently  used  in  the  form  of  whisky 
or  brandy.  In  numerous  cases  it  is  necessary  to  give  it  in  compara- 
tively large  doses,  particularly  in  the  more  severe  types  of  the  disease, 
when  as  much  as  1  dram  hourly  may  be  required,  although  in  most 
instances  half  of  this  amount  is  sufficient. 

Serum  Treatment. — To  Behring  belongs  the  credit  of  having  de- 
veloped the  use  of  antitoxin.  In  1890  he  announced  that  the  serum 
of  an  animal  which  had  been  immunized  against  diphtheria  was 
capable,  when  injected  into  other  animals,  of  giving  immunity  to  the 
disease,  and  also  to  effect  a  cure  in  those  suffering  from  it.  As  to  the 
exact  manner  in  which  antitoxin  acts,  no  satisfactory  explanation  has 
as  yet  been  given,  but  in  all  probability  it  exerts  its  good  effect  by 
neutralizing  the  toxins  of  the  disease.  It  is  probably  a  globulin, 
which  combines  with  the  globulin  of  the  blood,  and  so  prevents  the 
growth  of  the  organisms. 

The  serum  itself  should  be  clear,  though  its  color  varies.  It  fre- 
quently contains  a  preservative  such  as  carbolic  acid,  but  should  be 
kept  in  a  cool  place  in  an  hermetically  sealed  bottle.  As  a  rule  each 
cubic  centimeter  is  equivalent  in  strength  to  from  100  to  500  anti- 
toxin units.  The  animal  commonly  used  is  a  horse  which  is  positively 
free  from  glanders  or  tuberculosis.  According  to  Park,  the  serum  is 
produced  by  the  Health  Department  of  New  York  City  in  the  follow- 
ing manner: 

A  virulent  culture  of  a  Klebs-Loeffler  bacillus  at  the  end  of  a  week's 
growth  is  rendered  sterile  by  the  addition  of  10  per  cent,  of  a  5  per  cent, 
solution  of  carbolic  acid.  This  is  filtered  through  sterile  filter  paper, 
and  after  standing  twenty-four  hours  is  placed  in  bottles  and  kept  in 
a  cool  place.  Several  horses  are  then  injected  with  sufficient  toxin  to 
kill  10,000  guinea-pigs,  each  weighing  250  grams.  Ten  thousand  units 
of  antitoxin  are  injected  with  each  injection  of  toxin.  This  produces 
fever,  but  after  it  has  subsided,  which  is  usually  from  three  to  five 
days,  another  and  larger  dose  is  injected.  The  doses  of  toxin  are 
increased,  and  given  at  intervals  from  five  to  ten  days,  and  at  the 
end  of  two  months'  time  anywhere  from  ten  to  twent}^  times  the 


678  THE  SPECIFIC  INFECTIOUS  DISEASES 

original  amount  is  given.  The  horses  are  then  bled,  and  the  blood 
serum  is  tested  for  antitoxin.  Those  animals  which  yield  less  than 
200  units  to  each  cubic  centimeter  are  considered  unfit  for  use.  The 
remainder  are  subsequently  given  toxin  in  ascending  doses  and  at  the 
end  of  three  months  the  serum  from  such  animals  should  contain  from 
300  to  800  units  of  antitoxin  to  each  cubic  centimeter.  The  serum  is 
obtained  by  inserting  a  camiula  into  the  jugular  vein  of  the  horse, 
and  the  blood  is  received  in  Ehrlenmeyer  flasks,  allowed  to  clot,  and 
the  serum  removed.  The  antitoxin  unit  is  the  amount  of  antitoxin 
sufficient  to  prevent  the  death  of  a  guinea-pig  weighing  250  grams  from 
the  effect  of  100  fatal  doses  of  toxin. 

Dosage. — Large  doses  of  antitoxin  are  to  be  preferred  under  certain 
conditions  to  small  ones,  large  amounts  being  required  to  neutralize 
the  harmful  "toxin"  and  the  so-called  "toxone."  The  latter  is  sup- 
posed to  be  responsible  for  the  paralysis,  and  is  only  loosely  taken 
up  by  antitoxin,  and  not  in  any  great  degree  until  all  the  "toxin" 
has  been  neutralized.  This  hypothesis  seems  to  explain  why  antitoxin 
exerts  a  less  favorable  eft'ect  upon  diphtheritic  paralysis  than  one 
would,  perhaps,  expect. 

The  severity  of  the  attack,  and  to  a  less  extent  its  duration,  should 
be  the  most  important  guides  in  regulating  the  dosage.  For  many 
years  small  doses,  namely,  1000  to  2000  units,  were  given,  and  these 
repeated  at  frequent  intervals,  if  necessary.  Studies  made  in  recent  years 
have  demonstrated  that  it  is  more  advantageous  to  give  a  larger  dose 
early  in  the  disease,  such  as  4000  to  5000  units,  and  that  it  is  unneces- 
sary to  give  doses  at  such  frequent  intervals,  it  being  sufficient  to 
repeat  the  dose  after  the  lapse  of  twelve  to  eighteen  hours.  The  total 
amount  of  antitoxin  to  be  given  during  the  course  of  the  disease  depends 
entirely  upon  the  reaction  obtained;  in  the  majority  of  cases  it  is 
not  often  necessary  to  administer  more  than  15,000  units  during  the 
course  of  the  illness,  and  in  many  cases  a  single  injection  of  5000  units 
is  all  that  is  required. 

The  method  of  administration  is  as  follows:  A  syringe  is  necessary 
which  can  easily  be  disinfected  by  boiling,  and  should  be  sufiicienth^ 
large  to  hold  10  c.c.  The  site  of  injection  is  of  little  import,  though 
the  abdominal  wall  and  the  small  of  the  back  are  faA'orable  locations. 
The  skin  should  be  cleansed  with  soap  and  water,  followed  by  alcohol, 
and  all  air  should  be  expelled  from  the  syringe.  The  serum  is  intro- 
duced slowly,  and,  after  withdrawing  the  needle,  a  small  wad  of  sterile 
cotton  should  be  placed  over  the  seat  of  puncture.  Slight  pain  and 
general  discomfort  may  follow  its  use. 

Limitations  of  Antitoxin. — When  given  early  in  the  course  of  the 
disease  the  membrane  ceases  to  spread,  becomes  soft,  and  loosens,  often 
in  the  most  striking  manner.  The  nasal  discharge  diminishes,  and 
within  a  few  hours  the  temperature  often  subsides,  the  heart  action 
improves,  and  the  nervous  symptoms  lessen  materially.  When  given 
late,  antitoxin  cannot  be  expected  to  undo  the  harm  which  has  already 
been  done,  nor  is  it  likely  to  have  any  influence  on  the  other  organisms 


DIPHTHERIA  679 

so  frequently  associated  with  the  Klebs-Loeffler  bacilkis.  Again,  in 
some  instances,  even  though  antitoxin  be  given  early,  the  poisoning 
seems  to  be  so  virulent' that  the  antitoxin  has  little  or  no  effect.  In 
these  cases,  owing  to  the  more  rapid  result  produced,  the  intravenous 
or  intramuscular  injection  of  antitoxin  is  of  advantage. 

Bronchopneumonia  is,  of  course,  commonly  associated  with  the 
streptococcus  and  pneumococcus.  But  recent  studies  have  proven 
that  the  diphtheria  bacillus  is  more  commonly  than  formerly  supposed 
the  cause  of  bronchopneumonia,  and  it  may  be  the  sole  cause.  Pneu- 
monia has  been  produced  in  rabbits  by  the  Klebs-Loeffler  bacilli 
inoculated  into  the  larynx.  Large  doses  of  antitoxin  have  proven  of 
marked  benefit  in  some  pneumonia  patients,  and  it  is  well  to  give  the 
child  the  benefit  of  the  doubt  in  appropriate  cases. 

The  immunizing  power  which  antitoxin  has  is  shown  by  the  fact 
that  it  w^ill  protect  one  from  an  attack  of  the  disease,  although  the 
immunity  so  produced  lasts  but  three  or  four  weeks;  this,  however, 
can  be  prolonged  by  subsequent  injections.  The  curative  power  of 
antitoxin  is  well  attested  by  the  lessened  mortality  since  its  use, 
the  death-rate  having  dropped  at  least  50  per  cent.  The  following 
table  shows  the  average  annual  deaths  from  diphtheria  and  croup  per 
10,000  of  the  population: 

Before  antitoxin,        Since  antitoxin, 

1887  to  1893.  1896  to  1900. 

Per  cent.  Per  cent. 

London 4.8  4.7 

Berlin 10.2  3.7 

Paris ' 6.5  1.3 

New  York 14.5  6.3 

Chicago .13.1  5.0 

Denver 12.9  1.7 

Philadelphia  (1890-1894) 11.9  9.6 

In  Berlin  and  Paris,  where  the  serum  was  employed  freely,  the 
beneficial  results  can  be  seen  by  a  glance  at  the  above  table;  whereas 
in  some  American  cities,  where  the  serum  was  not  adopted  by  the 
local  Bureaus  of  Health,  the  reduction  in  mortality  was  not  so 
great. 

From  the  foregoing  facts  may  be  summarized  the  following: 

First. — In  view  of  the  lessened  mortality  and  the  marked  influence 
upon  the  course  of  the  disease,  Behring's  antitoxin  is  practically  a 
specific  remedy,  if  given  early  in  the  disease. 

Second. — In  doubtful  cases  it  should  be  given  rather  than  await 
the  findings  of  a  bacteriological  culture.  This  is  especially  recom- 
mended in  younger  children,  in  view  of  the  fact  that  antitoxin  is 
harmless  when  given  to  perfectly  healthy  persons. 

Third. — The  amount  of  antitoxin  given  depends  upon  the  severity 
of  the  illness  and  its  duration,  larger  doses  at  long  intervals  being  of 
more  benefit  than  frequently  repeated  small  doses. 

Fourth. — Diphtheria  antitoxin  cannot  be  expected  to  have  any 
beneficial  influence  upon  conditions  which  are  the  eft'ect  of  other 
organisms  associated  with  the  Klebs-Loeffler  bacillus. 


680  THE  SPECIFIC  IXFECTIOUS  DISEASES 

Fifth. — All  indi^"iduals,  especially  children,  who  have  come  in 
contact  with  a  case  of  diphtheria,  should  be  given  an  immunizing 
dose  of  serum. 

Sixth. — As  some  hours  must  elapse,  probably  twenty-four,  at  least, 
before  we  get  the  full  effect  of  antitoxin  injected  under  the  skin,  there- 
fore in  toxic,  laryngeal,  and  all  other  cases  where  a  prompt  reaction 
from  the  antitoxin  is  desired,  it  is  advisable  to  inject  it  intravenously, 
since  the  benefits  from  intravenous  injection  are  often  noticeable  within 
a  few  hours  after  its  administration.  If,  owing  to  the  small  size  of 
the  vein,  it  is  impossible  to  administer  it  intravenously,  the  antitoxin 
should  then  be  injected  into  the  muscle  instead  of  under  the  skin. 

In  the  present  state  of  our  knowledge,  should  anaphylaxis  influence 
in  any  degree  the  giving  of  diphtheria  antitoxin?  Elmer  E.  Heg,  in 
an  article  on  "Review  of  Theories  of  Anaphylaxis"  in  Northwest 
Medicine,  WTites:  "As  we  all  know,  quite  a  number  of  sudden  deaths 
have  followed  the  use  of  diphtheria  antitoxins,  a  number  of  them  in 
cases  of  asthma,  though  some  without  history  of  asthma.  In  most, 
no  history  is  given  as  to  whether  or  not  a  previous  injection  of  serum 
had  ever  been  given.  Goodall  reports  90  cases  in  a  children's  hospital, 
in  which,  during  a  period  of  five  years,  there  was  a  record  of  a  second 
injection  after  the  incubation  period.  Sixty  gave  evidences  of  reaction, 
mostly  a  rash  of  more  than  usual  severity;  7  had  severe  symptoms; 
1  convulsions;  2  collapse,  and  7  had  chills  and  temperature  as  high 
as  105°  F.;  all  recovered." 

Much  literature  has  accumulated  on  the  theories,  phenomena, 
lesions  and  mode  of  death  in  anaphylaxis  in  the  lower  animals,  but 
one  has  some  difficulty  in  finding  much  in  literature  regarding  the 
serious  results  of  anaphylaxis  in  man. 

G.  B.  Ker,  of  Edmburgh,  advises  caution  in  the  admmistration  of 
antitoxm  in  the  treatment  of  relapses.  He  says:  "Some  caution 
should  be  exercised  in  the  administration  of  antitoxin  in  the  treat- 
ment of  relapses.  It  is,  on  the  whole,  wiser  to  withliold  serum  if  it 
has  been  given  during  the  original  attack.  Owmg,  doubtless,  to 
what  is  termed  '  anaphylaxis'  the  sequelse  of  antitoxin  are  much  more 
severe  and  much  more  frequent  than  we  are  accustomed  to  see  in  a 
primary  case.  Very  profuse  and  irritating  rashes,  severe  joint  pams, 
and  smart  febrile  reactions  are  all  liable  to  occur  early.  A  relapse 
is  usually,  though  not  always,  comparatively  mild,  and,  if  there  is  not 
much  evidence  of  toxemia  and  the  larynx  is  not  implicated,  the  serum 
can  be  dispensed  with.  I  never  hesitate,  however,  to  give  liberal  doses 
if  the  symptoms  are  in  the  least  urgent." 

Dr.  E.  H.  Funk  has  given  me  some  interestmg  data  from  the 
^Municipal  Hospital  in  Philadelphia.  During  a  period  of  some  months 
he  had  an  opportunity  of  seeing  all  the  children  in  the  scarlet  fe^•er 
hospital,  and  during  a  similar  period  all  the  children  in  the  diphtheria 
hospital.  All  children  in  both  of  these  hospitals  are  given  one  or 
more  doses  of  antitoxin,  and  the  curative  doses  are  large  ones.  In 
the  aggregate,  a  number  of  these  cases  have  previously  received  either 


DIPHTHERIA  681 

immunizing  or  curative  doses  of  antitoxin.  Some  children  are  known 
to  have  been  given  antitoxin  on  three  different  occasions,  the  intervals 
between  the  administrations  being  months  or  years.  Rashes,  joint 
pains  and  slight  febrile  disturbances  were  occasionally  seen,  and  yet 
no  symptoms  of  a  serious  nature  were  ever  observed. 

A  very  unusual  opportunity  has  been  offered  to  study  the  results 
of  repeated  injections  of  antitoxin  at  the  Widener  Memorial  School 
for  Crippled  Children,  in  Philadelphia.  Dr.  Albert  D.  Ferguson  and 
Dr.  William  J.  Merrill  have  kindly  furnished  me  with  the  following 
data :  From  60  to  90  children  are  in  the  home,  the  buildings  being  all 
modern  and  thoroughly  up-to-date.  Many  of  these  children  remain 
for  years  as  inmates.  In  spite  of  all  precautions  an  occasional  case  of 
diphtheria  occurs.  An  immunizing  dose  of  1000  units  is  always  given 
to  all  children  who  have  been  exposed,  and  large  curative  doses  are 
administered.  As  a  result  of  this  policy,  and  the  fact  that  children 
often  remain  for  years  in  the  home,  it  has  happened  that  many  children 
have  received  a  number  of  doses  of  antitoxin  at  intervals  of  a  few 
months.  It  is  understating  the  case  to  say  that  many  children  have 
received  diphtheria  antitoxin  on  at  least  six  different  occasions. 
Rashes,  joint  pains  and  slight  fever  are  occasionally  seen,  but  no 
fatal  case,  or  even  alarming  symptoms,  have  ever  occurred.  It  seems 
only  just  to  conclude  from  this  that  with  our  present  knowledge  one 
should  disregard  completely  anaphylaxis  in  treating  diphtheria  cases, 
and  use  antitoxin,  according  to  modern  ideas,  at  the  earliest  possible 
moment,  both  for  immunizing  and  curative  effects. 

Future  study  is  required  to  explain  the  symptoms  in  certain  cases. 
Several  cases  have  been  reported  where  physicians,  taking  an  immu- 
nizing dose  of  1000  units,  have  had  marked  symptoms,  such  as 
unconsciousness  and  severe  rash. 

To  those  who  are  influenced  by  anaphylaxis  it  may  be  pointed  out 
that  the  concentrated  serum  is  safer,  inasmuch  as  a  smaller  measure 
by  quantity  is  required.  And  as  the  intravenous  injection  gives  a 
more  marked  and  rapid  result,  the  subcutaneous  method  is  to  be 
preferred,  since  the  dangerous  symptoms  develop  soon  after  the  injec- 
tion is  given,  and  it  is  reasonable  to  suppose  that  the  slower  absorption 
of  the  subcutaneous  method  is  safer,  therefore,  than  the  intravenous. 

A  conservative  and  safe  method  has  been  advocated,  which  should 
appeal  to  physicians  and  be  applicable  to  a  large  number  of  cases; 
in  fact,  could  be  used  in  all  patients,  except  where  the  symptoms 
were  so  urgent  that  a  delay  of  a  few  hours  might  be  dangerous  to  the 
life  of  the  individual.  This  consists  in  giving  a  small  initial  dose  of 
antitoxin,  about  the  usual  immunizing  dose,  in  all  cases  where  a 
previous  injection  of  antitoxin  has  been  administered.  If  no  immediate 
reaction  is  observed,  it  is  safe  in  a  few  hours  to  administer  the  remedy 
in  appropriate  curative  doses.  If  the  case  shows  an  immediate  reac- 
tion it  is  wiser  not  to  administer  a  large  dose,  as  it  might  not  be 
safe.  If  the  immediate  reaction  has  occurred,  the  patient  will  have 
milder  symptoms  from  the  smaller  dose,  on  the  theory  that  the  larger 


682  THE  SPECIFIC  INFECTIOUS  DISEASES 

the  dose,  the  more  severe  the  immediate  reaction.  Recently,  in  the 
Jefferson  Hospital,  we  have  been  using  the  Schick  reaction  with  fairly 
satisfactory  results. 

By  its  use  one  is  able  to  separate  the  children  that  should  receive 
diphtheria  antitoxin  from  those  to  whom  it  should  not  be  administered. 
In  my  judgment  the  Schick  test  is  practicable  only  in  those  institutions 
that  have  adequate  observation  wards.  Children  who  are  admitted 
for  adenoid  and  tonsil  operations  often  leave  the  hospital  in  twenty- 
four  hours  after  admission.  In  these  cases  the  time  in  the  hospital 
is  often  insufficient  for  the  study  of  the  Schick  test.  In  the  hospitals 
where  childr^  are  admitted  directly  to  the  wards,  one  or  two  days 
must  elapse  after  the  test  is  made  before  it  is  possible  to  know  to  whom 
antitoxin  should  be  given.  During  this  interval  the  child  that  requires 
antitoxin,  either  as  a  prophylactic  measure  to  protect  himself  or  as 
a  protective  measure  for  the  other  children  in  the  ward,  has  received 
no  treatment. 

Antitoxin  Eruptions. — In  certain  instances  a  cutaneous  eruption 
follows  the  use  of  antitoxin.  This  eruption  may  make  its  appearance 
at  any  time  from  the  date  the  antitoxin  is  injected  up  to  a  period  of 
a  month  after  its  use,  but  usually  between  the  fifth  and  the  twelfth 
days.  Such  rashes  are  generally  urticarial  in  type,  sometimes  erythe- 
matous, and  the  latter  often  closely  resemble  the  rash  of  scarlet  fever. 

Other  types  of  eruption  which  may  occur  are  vesicular,  bullous,  and 
purpuric.  Accompanying  antitoxin  rashes  is  an  edema  of  the  skin, 
most  noticeable  on  the  face.  Though  this  rash  may  make  its  appear- 
ance on  any  surface  of  the  body,  it  is  generally  first  visible  about  the 
point  of  injection.  Constitutional  symptoms  in  the  form  of  fever 
which  lasts  two  or  three  days,  headache,  and  at  times  vomiting, 
usually  accompany  such  rashes.  Joint  involvement,  chiefly  pain,  at 
times  swelling,  is  a  notable  feature  in  many  instances. 

The  diseases  with  which  serum  rashes  are  apt  to  be  confounded  are 
scarlet  fever  and  measles,  and  sometimes  it  is  almost  impossible  to 
make  an  early  diagnosis.  As  a  rule  the  appearance  of  a  rash  after 
the  use  of  the  serum,  especially  its  appearance  first  at  the  site  of  the 
injection,  the  sudden  rise  in  temperature,  together  with  certain  joint 
symptoms,  should  be  a  guide  to  the  differentiation. 

Operative  Measures. — If,  after  the  use  of  antitoxin  and  other 
measures,  there  is  a  marked  increase  in  cyanosis  and  a  gradual  rise 
of  temperature,  intubation  or  tracheotomy  should  be  performed. 
Which  is  indicated  should  be  decided  by  the  attending  physician.  In 
this  country  intubation  seems  to  have  the  preference,  though  there  are 
instances  in  which  tracheotomy  is  necessary,  either  because  of  the 
location  of  the  membrane,  a  lack  of  skill  in  performing  intubation, 
or  some  other  concurrent  condition.  Too  frequently  is  tracheotomy 
postponed,  consequently  the  results  are  often  not  as  good  as  they 
might  be. 

Intubation. — We  are  indebted  to  Dr.  Joseph  O'Dwyer,  of  New  York, 
for  this  operation.     A  set  of  instruments  consists  of  seven  tubes,  an 


DIPHTHERIA  683 

introducer,  an  obturator,  a  mouth  gag,  a  gauge  for  measuring  the  size 
of  the  tubes,  and  an  extractor.  The  tubes  vary  both  in  size  and 
caHbre  so  that  they  may  be  inserted  into  the  larynx  of  a  child  of  any 
age.  They  are  made  of  hard  rubber  lined  with  metal.  The  head  of 
the  tube  is  oval,  and  on  its  left  side  is  a  small  hole  through  which  a 
string  can  be  passed.  This  is  to  enable  the  operator  to  withdraw  the 
tube  should  it  be  introduced  into  the  esophagus  instead  of  the  larynx. 
Each  tube  contains  an  obturator  which  is  fastened  to  the  introducer 
before  the  tube  is  inserted.  The  extractor  is  so  constructed  that 
when  its  tip  is  introduced  into  the  tube  the  action  of  a  lever  makes  its 
jaws  separate,  and  the  tube  is  grasped  and  extracted. 

For  the  introduction  of  the  tube  the  child  should  preferably  be  upon 
its  back,  with  the  hands  fastened  to  the  sides.  A  gag  is  then  placed 
in  its  mouth,  and  the  mouth  opened  widely.  The  tube  is  then  attached 
to  the  introducer,  and  the  index  finger  of  the  left  hand  is  inserted 
into  the  pharynx  until  the  epiglottis  is  located  and  pulled  forward. 
Then,  with  the  right  hand,  the  operator  passes  the  introducer  with 
attached  tube  backward  to  the  glottis,  and  on  releasing  the  introducer 
by  means  of  an  attached  thumb-piece,  the  tube  immediately  passes 
into  the  larynx. 

The  obturator  is  then  removed,  while  the  tube  is  held  in  position 
by  the  tip  of  the  finger.  That  the  tube  is  in  the  proper  position  is 
soon  indicated  by  the  sudden  relief  of  the  dyspnea.  In  the  meantime 
the  attached  string  should  be  firmly  held  for  fear  the  tube  may  have 
been  inserted  into  the  esophagus.  Should  this  occur,  the  tube  must 
immediately  be  pulled  out.  The  string  may  be  removed  by  cutting 
it,  and  pulling  it  through  the  hole  in  the  head  of  the  tube. 

Sometimes  it  is  necessary  to  let  the  string  remain  attached  because 
of  the  possibility  of  the  tube  becoming  obstructed  by  membrane  from 
below.  In  such  cases  the  string  may  be  securely  fastened  to  the  side 
of  the  face  by  a  piece  of  adhesive  plaster,  or  the  loop  may  be  carried 
over  the  ear.  In  addition  to  the  sudden  relief  of  dyspnea  when  the 
tube  is  properly  inserted  in  the  larynx,  we  usually  note  a  severe 
metallic  cough,  and  that  the  breath  sounds  assume  a  hissing  character. 

Dangers  of  Intubation. — In  the  hands  of  an  unskilful  operator 
much  harm  can  be  done,  such  as  forcing  the  exudate  downward  into 
the  trachea  by  the  tube,  thus  causing  instant  death.  False  passages 
may  be  made  by  forcible  introduction,  or  asphyxia  may  result  from  too 
frequent  attempts. 

After-treatment. — Sometimes,  after  intubation,  the  tube  is  expelled, 
usually  owing  to  the  fact  that  it  is  of  too  small  size.  In  all  cases  of 
dyspnea  after  intubation,  a  careful  examination  should  be  made  to 
ascertain  whether  or  not  the  tube  is  really  in  the  larynx,  for  it  is 
possible  for  it  to  be  coughed  up  unnoticed,  or  it  may  be  coughed  up 
and  swallowed  by  the  child. 

The  most  perplexing  question  after  intubation  is  in  regard  to  the 
feeding.  In  some  cases  it  is  practically  impossible  for  the  patient  to 
swallow  liquids,  whereas  in  others  they  are  swallowed  without  any 


684  THE  SPECIFIC  INFECTIOUS  DISEASES 

difficulty  whatsoever.  Coughing  is  brought  on  probably  by  some  of 
the  fluid  getting  into  the  trachea  through  the  tube,  and  in  consequence 
most  of  the  liquid  is  expelled.  This  condition  happily  disappears 
after  two  or  three  days,  but  during  the  time  it  lasts  it  is  often  necessary 
to  resort  to  semisolid  food,  such  as  scrambled  eggs,  junket,  etc. 

Casselberry,  of  Chicago,  advocates  having  the  child  lie  with  its 
head  low6r  than  its  body  while  on  its  back,  so  that  liquids  which  may 
gain  access  to  the  tube  may  have  a  better  chance  to  run  out.  Should 
this  fail,  it  may  be  necessary  to  resort  either  to  gavage  or  feeding  by 
the  rectum.  The  former  is  accomplished  by  the  introduction  of  a 
small  soft-rubber  catheter  through  the  nose  into  the  stomach.  Infants 
who  are  breast-fed  are  usually  able  to  swallow  with  little  difficulty.  A 
nipple  shield  should,  however,  always  be  used,  or  the  child  should  be 
fed  breast  milk  from  a  nursing  bottle. 

To  prevent  the  possible  expulsion  of  the  tube,  children  should  not 
be  held  with  the  face  downward  nor  should  they  be  allowed  to  lie 
upon  the  face;  in  either  of  these  positions  the  tube  may  be  readily 
expelled  with  the  slightest  cough. 

The  length  of  time  necessary  for  the  tube  to  remain  in  the  larynx 
varies  greatly  in  each  case.  Usually  it  should  be  allowed  to  remain 
for  at  least  five  days,  though  there  are  instances  where  it  may  be 
removed  after  two  or  three  days.  Sometimes  the  tube  is  coughed  up 
with  a  mass  of  membrane,  and  in  such  instances  it  is  well  to  withhold 
its  reintroduction,  as  this  may  be  unnecessary,  but  should  signs  of 
dyspnea  return,  it  must  be  reintroduced  immediately.  Should  the 
tube  become  obstructed,  it  must  be  removed,  and  if  coughed  up  or 
swallowed  no  alarm  need  be  felt,  as  it  is  invariably  passed  from  the  bowel. 

Extubation  or  Removal  of  the  Tube. — This  procedure  is  considered 
more  difficult  than  its  introduction,  and  the  technic  is  identically 
the  same  as  that  of  intubation.  The  child  is  placed  in  the  same  posi- 
tion, the  mouth  is  held  open  by  the  use  of  the  gag,  the  index  finger 
of  the  left  hand  is  passed  backward  until  the  tip  of  the  finger  touches 
the  head  of  the  tube,  the  epiglottis  is  then  tilted  forward,  the  extractor 
is  inserted  with  the  right  hand  along  the  side  of  the  finger,  and  the 
beak  of  the  instrument  is  inserted  into  the  opening  of  the  tube.  The 
extractor  is  then  pressed  down,  which  causes  the  two  ends  of  the 
instrument  to  separate,  and  thus  grasp  the  tube,  which  is  then  lifted 
out.  Should  there  be  any  difficulty  in  removing  the  tube,  it  is  wise 
not  to  continue  the  attempts  too  long,  but  to  stop  for  awhile,  and 
later  try  again.  Should  dyspnea  occur,  reintubation  is  imperative, 
consequently  all  cases  of  extubation  should  be  carefully  watched  for 
the  following  hour. 

Morphine  is  usually  given  hypodermically  after  extraction,  and 
an  ice-bag  placed  over  the  larynx.  Immediately  after  extubation  all 
irritative  influences  should  be  guarded  against,  and  the  child  should 
be  kept  in  bed  for  at  least  two  days. 

Prolonged  Intubation. — There  are  cases  in  which  it  is  necessary  for 
the  tube  to  remain  in  the  larynx  for  a  long  period  of  time,  the  children 


DIPHTHERIA  685 

becoming  markedly  dyspneic  soon  after  the  tube  is  removed,  which 
necessitates  its  immediate  replacement.  In  such  cases  the  tube  may 
be  expelled  at  frequent  intervals,  necessitating  tracheotomy  in  order 
to  prevent  possible  suffocation  should  they  be  where  it  is  impossible 
immediately  to  replace  the  tube. 

Various  changes  in  the  larynx,  such  as  thickening,  cicatricial  con- 
tractions, paralysis  of  the  muscles,  persistence  of  false  membrane,  etc., 
may  necessitate  prolonged  intubation,  though  frequently  the  true 
cause  is  undeterminable.  Inasmuch  as  tubes  may  produce  ulceration 
of  the  larynx,  they  should  be  removed  early  when  possible,  but  not 
until  the  condition  of  the  patient  warrants  it.  After  the  removal  of 
a  tube  its  reinsertion  is  sometimes  impossible.  In  such  instances, 
should  alarming  symptoms  occur,  tracheotomy  is  necessary.  For 
the  ulceration  which  frequently  follows  the  use  of  the  tube,  O'Dwyer 
has  advised  the  coating  of  tubes  with  astringents. 

For  chronic  inflammatory  conditions  of  the  mucous  and  submucous 
membranes  of  the  larynx,  Rogers  has  advised  increasing  the  intra- 
laryngeal  pressure  by  gradually  inserting  larger  tubes  until  the  largest 
sized  tube  has  been  worn  for  several  weeks.  This  is  then  removed. 
In  this  way  he  has  succeeded  in  dispensing  with  tubes  which,  in  some 
cases,  had  been  used  for  two  or  three  years.  In  chronic  stenosis  of 
the  larynx,  O'Dwyer  has  advised  opening  the  trachea,  producing 
dilatation  from  below,  and  then  inserting  an  intubation  tube. 

Tracheotomy. — In  recent  years  this  method  of  relief  from  laryngeal 
obstruction  has  fallen  into  comparative  disuse,  largely  owing  to  the 
beneficial  results  of  diphtheria  antitoxin,  and  to  the  practice  of  intu- 
bation which  has  replaced  it.  However,  there  are  still  occasions  which 
call  for  this  radical  procedure,  i.e.,(l)  When  the  membrane  has  become 
loosened  in  the  larynx,  and  intubation  may  force  it  farther  down. 
(2)  When  the  membrane  has  been  forced  dow^n  into  the  larynx  by 
unsuccessful  attempts  at  intubation.  (3)  When  membrane  formation 
is  too  extensive  to  be  relieved  by  intubation,  and  when  cases  have 
been  intubated,  and  the  membrane  has  formed  below  the  tube.  While 
the  operation  of  intubation  appears  to  be  a  simple  one,  it  is  often 
very  difficult  to  perform,  and  a  competent  and  experienced  surgeon 
should  always  be  secured  to  do  it. 

The  occurrence  of  laryngeal  diphtheria  can  to  some  extent  be 
prevented  by  an  early  diagnosis  and  promptitude  in  treatment,  thus 
lessening  the  possibility  of  extension  of  the  membrane  into  the  larynx. 
When  the  larynx  becomes  involved  the  membrane  slowly  disinte- 
grates, becomes  detached,  and  is  expelled,  consequently  it  is  some- 
times advisable  to  give  an  emetic  to  promote  its  expulsion.  Of  course, 
this  ought  not  be  done  unless  the  physician  feels  positive  that  the 
membrane  is  detached,  and  this  is  certain  only  when  a  peculiar  flapping 
sound  is  heard  in  the  larynx. 

Syrup  of  ipecac,  in  |-  to  1-dram  doses,  is  in  all  probability  the  most 
efficacious  emetic  to  use  in  such  circumstances,  because  it  leaves  no 
after-eft'ects.     Apomorphine,  2V  gi"ain,  may  also  be  used. 


686  THE  SPECIFIC  INFECTIOUS  DISEASES 

Inhalations  of  steam  were  formerly  quite  generally  used  to  detach 
the  false  membrane,  but  because  of  their  depressing  effect  they  are 
now  seldom,  if  ever,  resorted  to.  In  addition  to  inhalations  of  medi- 
cated vapors,  such  as  the  compound  tincture  of  benzoin,  turpentine, 
etc.,  the  internal  use  of  mercury  has  gained  much  favor.  It  may  be 
given  in  the  form  of  calomel,  in  divided  doses,  extending  over  a  period 
of  from  twelve  to  twenty-four  hours. 

Before  the  introduction  of  antitoxin,  calomel  by  fumigation  was 
frequently  emplo^'ed  in  the  treatment  of  laryngeal  diphtheria,  and 
there  is  much  clinical  evidence  in  favor  of  its  use.  Ten  grains  of 
calomel  are  dropped  on  a  strip  of  tin,  which  is  placed  over  a  chamber. 
A  lighted  alcohol  lamp  or  candle  is  placed  in  the  chamber  under  the  tin. 
The  crib  or  bed  is  surrounded  by  sheets  to  form  a  tent,  and  the  patient 
and  nurse  remain  in  the  tent  for  ten  to  fifteen  minutes,  the  nurse 
frequently  taking  long  breaths  of  outside  air  from  the  opening  in  the 
tent.  The  patient  apparently  runs  no  risk  of  salivation,  and  the 
above  precaution  will  protect  the  nurse.  The  fumigation  may  be 
repeated  three  or  four  times  a  day. 

PSEUDODIPHTHERIA. 

Synonyms:  False  Diphtheria — Scarlatinal  Diphtheria — Croupous 
Tonsillitis — Streptococcus  Diphtheria. 

Under  this  term  may  be  grouped  those  inflammatory  conditions 
of  the  mucous  membrane  of  the  throat  and  upper  air  passages  in 
which  is  produced  a  false  membrane  which  is  not  associated  with  the 
Klebs-Loeffler  bacillus.  Because  of  the  fact  that  the  Streptococcus 
pyogenes  is  frequently  found  in  such  membranes,  it  is  often  called 
Streptococcus  diphtherise.  A  diplococcus,  called  the  Roux  coccus,  has 
also  been  isolated,  and  the  Staphylococcus  pyogenes  may  frequently 
be  found  in  cases  of  pseudodiphtheria.  Among  the  organisms  which 
may  cause  membranous  formations  in  the  mouth  and  tlu"oat  are  the 
pneumococcus,  the  Bacillus  coli,  and  even  the  gonococcus.  The  affec- 
tion is  frequently  confounded  with  diphtheria,  and  it  has  been  esti- 
mated that  from  25  to  35  per  cent,  of  cases  formerly  thought  to  be 
diphtheria  were  nothing  more  than  pseudodiphtheria. 

The  diseases  in  which  pseudomembranous  inflammation  is  most  apt 
to  appear  are  scarlet  fever,  measles,  whooping-cough,  and  typhoid  fever. 
It  may  also  develop  as  a  primary  affection.  The  general  hygienic 
surroundings  seem  to  have  some  bearing  upon  the  development  of  the 
disease,  in  that  it  is  more  frequently  seen  in  children  living  in  insani- 
tary tenement  houses,  or  among  the  inmates  of  institutions.  The 
disease  itself  is  but  slightly  contagious,  which  renders  isolation  and 
disinfection  during  its  course  unnecessary. 

Lesions. — The  tonsils  are,  as  a  rule,  the  chief  seat  of  membrane 
formation,  save  in  secondary  cases  where  the  entire  pharynx  may 
be  involved  with  extension  to  the  mouth,  nose,  middle  ear,  and,  in 
exceptional  instances,  to  the  larynx,  trachea,  and  bronchial  tubes. 


PSEUDODIPHTHERIA  687 

The  membrane  difi'ers  from  that  of  diphtheria  in  that  it  is  softer, 
and  microscopically  is  found  to  contain  a  greater  proportion  of  cells 
than  the  membrane  of  diphtheria.  Nevertheless,  it  is  practically 
impossible  to  distinguish  the  membranes  of  the  two  diseases  micro- 
scopically, and  in  the  majority  of  instances  a  bacteriological  culture 
is  necessary  in  order  to  make  a  diagnosis.  The  non-adherency  of  a 
pseudomembrane  in  primary  cases  is  characteristic,  whereas  in  second- 
ary cases  the  pseudomembrane  may  extend  deeper,  and  the  adjacent 
tissues  become  markedly  congested  and  edematous,  this  affecting 
chiefly  the  tonsils,  soft  palate,  and  uvula.  In  some  cases  membranous 
casts  of  the  larynx  and  trachea  have  been  expelled. 

Symptoms. — The  onset  is  sudden,  accompanied  by  headache, 
vomiting,  chills,  loss  of  appetite,  difficulty  in  swallowing,  and  sore 
throat.  On  inspection  the  tonsils  are  found  to  be  reddened  and 
swollen,  and  are  soon  after  the  seat  of  membranous  patches.  The 
membrane  is  usually  yellow  or  gray,  and  loosely  adherent,  and,  after 
three  or  four  days'  duration,  disappears.  The  surrounding  tissues 
are  at  the  same  time  markedly  inflamed,  and  the  lymphatics  behind  the 
angle  of  the  jaw  are  tender  and  swollen,  and  may  suppurate.  The 
constitutional  symptoms  usually  subside  by  the  third  or  fourth  day. 

Secondary  cases  of  the  disease  in  severe  forms  are  usually  seen  in 
scarlet  fever  or  measles.  When  accompanying  scarlet  fever,  evidences 
of  the  disease  may  present  themselves  either  at  the  beginning  or 
from  the  third  to  the  fifth  day;  whereas,  when  complicating  measles, 
they  are  usually  at  their  height  when  the  eruption  begins  to  disappear. 
Sometimes  the  larynx  is  involved,  and  then  bronchopneumonia  is  apt 
to  develop. 

In  the  secondary  type  of  the  affection  the  constitutional  symptoms 
are  usually  quite  severe.  There  is  high  fever,  the  pulse  becomes  rapid 
and  feeble,  prostration  is  great,  and  delirium  or  stupor  may  set  in. 
Following  such  an  attack  there  may  be  either  suppuration  or  necrosis 
of  the  adjacent  tissues.     Fortunately,  such  occurrences  are  rare. 

Diagnosis. — The  differentiation  between  pseudodiphtheria  and  true 
diphtheria  can  in  most  instances  be  made  only  by  means  of  a  bacteri- 
ological culture.  When  the  disease  is  secondary  to  scarlet  fever  or 
measles,  and  appears  during  the  height  of  the  primary  disease,  the 
diagnosis  is  not  so  difficult,  since  true  diphtheria  more  often  develops 
after  the  primary  fever  has  abated.  If,  in  such  cases,  the  first  culture 
is  negative,  a  second  should  always  be  made. 

Prognosis. — Primary  instances  of  the  disease  usually  terminate  in 
recovery,  the  mortality  being  extremely  low  (3.5  per  cent.)  whereas, 
when  secondary  to  one'  of  the  diseases  mentioned,  the  mortality  is 
usually  from  15  to  20  per  cent. 

Treatment. — All  cases  of  membranous  inflammation  of  the  throat 
should  be  isolated  and  regarded  with  suspicion.  In  very  young 
children  antitoxin  ought  to  be  administered  immediately,  and  a 
bacteriological  culture  then  made  to  determine  the  organisms  present. 
If  the  bacteriological  findings  prove  the  disease  to  be  non-diphtheritic, 


688  THE  SPECIFIC  INFECTIOUS  DISEASES 

the  administration  of  antitoxin  should  be  discontinued ;  but  in  no  case 
should  antitoxin  be  withheld  until  a  positive  diagnosis  of  diphtheria 
can  be  made. 

Locally  the  nose  and  throat  should  be  thoroughly  syringed  with 
mild  antiseptic  solutions,  such  as  liquor  alkalinus  antisepticus,  25 
per  cent.  In  instances  where  the  swelling  and  edema  are  marked,  a 
spray  of  1  to  10,000  adrenalin  chloride  solution  often  gives  great 
relief.  The  drugs  most  frequently  used  as  a  direct  application  to  the 
membrane  itself  are  nitrate  of  silver  in  the  form  of  a  10  to  15  per  cent, 
solution,  and  a  solution  of  bichloride  of  mercury,  1  to  1000. 

Should  there  be  evidences  of  adenitis  or  cellulitis,  the  external  appli- 
cation of  an  ice-bag  affords  great  relief.  Frequently  a  gargle  con- 
taining chlorate  of  potash,  10  grains  to  1  ounce,  in  combination  with 
tincture  of  ferric  chloride,  |  dram  to  1  ounce,  is  of  decided  benefit  in 
preventing  further  membrane  formation.  When  laryngeal  obstruc- 
tion occurs,  intubation  or  tracheotomy  may  sometimes  be  necessary 
as  in  true  diphtheria. 

PERTUSSIS   (WHOOPING-COUGH). 

Whooping-cough  is  a  contagious  disease,  characterized  by  catarrhal 
inflammation  of  the  mucous  membrane  of  the  respiratory  tract, 
together  with  irritability  of  the  nervous  system.  It  occurs  in  both 
epidemic  and  endemic  forms. 

It  is  essentially  a  disease  of  child  life,  being  seen  most  commonly 
in  the  first  five  years,  and  about  65  per  cent,  of  all  cases  occurring 
during  the  first  two  years.  It  often  attacks  infants  only  a  few  weeks 
or  months  old,  and  in  this  respect  differs  from  measles,  scarlet  fever, 
and  diphtheria,  which  are  rarely  met  with  at  this  early  age. 

It,  however,  occurs  quite  often  in  older  children,  is  occasionally 
seen  in  adult  life,  and  even  in  old  age.  It  is  very  contagious,  and  almost 
all  children,  especially  if  they  have  a  coryza  or  bronchitis,  will,  if 
exposed,  contract  the  disease. 

In  the  majority  of  instances  one  attack  confers  immunity,  second 
attacks  being  rare.  Winter  and  spring  are  the  usual  seasons  for  the 
prevalence  of  epidemics,  and  such  epidemics  frequently  either  precede 
or  follow  epidemics  of  other  contagious  diseases,  particularly  measles. 

The  disease  is  easily  communicated  from  one  person  to  another, 
most  frequently  by  direct  contact,  though  it  is  often  contracted  in  the 
open  air.  The  height  of  contagion  appears  to  be  in  the  early  or  catarrhal 
stage,  although  it  is  also  contagious  until  the  typical  whoop  disappears 
in  the  stage  of  decline. 

Children  who  are  delicate  or  anemic  are  more  susceptible  than 
others.  Bordet  and  Gengou  have  apparently  isolated  the  true  organism. 
They  describe  it  as  a  small,  ovoid  bacillus,  sometimes  elongated,  but 
more  often  so  short  as  to  resemble  a  micrococcus.  The  bacillus  stains 
a  pale  blue  with  Kuhne's  blue  stain,  and  is  negative  to  Gram's  stain; 
it  is  believed  by  some  authorities  to  belong  to  the  influenza  group. 


PERTUSSIS  689 

Pathology. — No  constant  pathological  lesions  are  found,  except  a 
catarrhal  inflammation  of  the  respiratory  tract,  and  sometimes  a 
serous  pleurisy.  The  paroxysms  have  been  attributed  to  irritation  of 
the  upper  air-passages  in  the  region  supplied  by  the  superior  laryngeal 
nerve,  or  to  an  irritation  in  the  posterior  part  of  the  larynx  between 
the  arytenoid  cartilages.  Another  view  is  that  the  paroxysms  of  cough- 
ing are  due  to  a  plug  of  mucus  in  the  trachea.  The  most  frequent 
complication  is  bronchopneumonia.  In  protracted  cases  the  lungs  are 
apt  to  show  some  degree  of  emphysema.  In  severe  cases  which  prove 
fatal,  hemorrhages  may  take  place  in  the  eye,  ear,  and  brain. 

Histological  studies  have  shown  that  jn  fatal  cases  of  whooping-cough 
the  action  of  the  infecting  bacilli  is  largely  mechanical,  since  they  are 
found  in  great  numbers  in  the  epithelial  lining  of  the  respiratory  tubes. 
There  is  also  produced  in  pertussis  a  mild  toxin  which  causes  exudation 
of  leukocytes  into  the  lumen  of  the  trachea  and  the  bronchi  from  blood- 
vessels lying  external  to  them. 

The  changes  which  occur  in  the  splenic  lymph  structures,  in  the 
lymph  nodes  of  the  gastro-intestinal  tract,  and  elsewhere  are  also 
produced  by  this  mild  toxin,  while  in  the  blood  there  is  lymphocytosis 
and  the  formation  of  an  antibody  which  acts  specifically  against  the 
Bordet-Gengou  bacillus. 

Symptoms. — The  period  of  incubation,  though  variable,  is  usually 
from  seven  to  fourteen  days.  For  convenience's  sake,  the  symptoms 
are  divided  into  three  groups :  the  catarrhal,  the  spasmodic,  and  those 
in  the  stage  of  decline. 

Catarrhal  Stage. — The  catarrhal  stage  gives  all  the  appearances  of  a 
simple  cold;  namely,  fever,  nasal  discharge,  and  cough.  These 
symptoms  may  be  preceded  by  a  period  of  anorexia,  languor,  and  rest- 
lessness, especially  at  night.  The  cough  also  is  most  troublesome 
at  night.  The  fever  may  be  slight  and  remittent,  and  is  present  only 
in  the  first  few  days  unless  complications,  such  as  severe  bronchitis 
or  bronchpneumonia,  develop.  Up  to  this  time  no  suspicion  is  aroused 
unless  there  is  a  history  of  direct  contact.  After  five  to  ten  days, 
however,  it  is  noticed  that  the  cough,  instead  of  abating,  is  more 
frequent,  and  becomes  spasmodic  in  character,  occurring  in  paroxysms 
which  gradually  increase  in  severity  and  are  especially  troublesome 
at  night,  until  the  appearance  of  the  typical  whoop  which  marks  the 
paroxysmal  stage.  Examination  of  the  chest  at  this  time  shows  a 
moderate  degree  of  bronchitis. 

Spasmodic  Stage. — In  this  stage  the  symptoms  and  physical  signs 
of  bronchitis  are  present,  and  the  paroxysms  of  coughing  gradually 
increase  in  number  and  severity.  During  the  coughing  the  child's 
face  becomes  congested,  and  the  eyes  suifused.  A  typical  seizure 
consists  of  a  number  (5  to  10  or  15)  of  short  expiratory  coughs  without 
a  single  inspiration  intervening.  At  the  end  of  these  expiratory  coughs 
there  is  a  long  drawn  out  inspiration,  and  it  is  this  inspiration  which 
produces  the  whoop.  This  is  followed  by  another  series  of  expiratory 
coughs,  then  by  another  whoop,  and  this  is  repeated  in  a  single 
44 


690  THE  SPECIFIC  INFECTIOUS  DISEASES 

paroxysm  two,  tliree,  or  even  six  times,  until  the  child  coughs  up  a 
portion  of  thick,  tenacious  mucus,  and  the  paroxysm  temporarily 
ceases. 

Infants  usually  foretell  the  approach  of  a  paroxysm  by  beginning 
to  cry,  and  older  children  run  to  their  parents,  or  support  themselves 
against  some  object  when  the  aura  of  vomiting  or  sneezing  warns 
them  of  the  coming  attack. 

As  the  attacks  become  more  severe,  there  may  be  hemorrhages 
into  the  skin,  nose,  throat,  or  conjunctivfe.  The  face  is  puffy,  especially 
about  the  eyelids,  and  there  may  be  a  great  amount  of  venous  stasis. 
Not  infrequently  well-marked  bronchitis  sets  m  at  this  stage  of  the 
disease. 

Vomiting  often  follows,  and  may  be  so  persistent  as  to  produce 
emaciation.  Epistaxis  sometimes  occurs  during  the  more  severe 
attacks,  although  the  amount  of  blood  lost  is  usually  slight.  Some 
degree  of  prostration  often  follows  the  paroxysms,  and  convulsions 
occur  in  severe  cases. 

The  number  of  attacks  during  the  day  varies  from  five  to  fifty, 
according  to  the  severity  of  the  infection,  and  they  may  be  provoked 
by  laughing,  crying,  overloading  the  stomach,  or  any  u-ritation  of  the 
nasopharynx  and  lar^Tix.    The  paroxysms  are  always  worse  at  night. 

In  very  young  children  the  whoop  is  frequently  absent,  though  the 
cough  may  be  severe.  The  duration  of  the  paroxysmal  stage  is  usually 
between  four  and  five  weeks;  in  the  milder  cases  it  may  last  but  a  week, 
and  in  the  more  severe  ones  may  continue  for  eight  or  ten  weeks, 
and  then  recur  upon  the  slightest  provocation,  such  as  a  cold.  As  a 
rule,  it  reaches  its  height  at  the  end  of  the  second  week,  remains 
constant  for  two  weeks,  and  then  gradually  subsides,  the  cough 
assuming  the  appearance  of  simple  bronchitis. 

Stage  of  Decline. — This  period  is  characterized  by  a  decrease  in  the 
severity,  and  diminished  frequency,  of  the  attacks.  The  cough  loses 
its  paroxysmal  form,  gradually  becomes  catarrhal,  and  disappears  in 
the  course  of  about  two  weeks. 

Complications. — Hemorrhages  frequently  occur  as  a  result  of  intense 
venous  congestion,  epistaxis  being  the  most  common,  though  rarely 
of  any  severity.  Conjunctival  hemorrhages,  bleeding  from  the  ears, 
petechise,  and,  occasionally,  hemoptysis  may  appear.  Convulsions 
sometimes  occur,  probably  as  the  result  of  engorgement  of  the  cortex, 
although  hemorrhagic  or  tuberculous  meningitis  may  set  in,  and 
encephalitis  has  been  reported. 

Hemiplegia,  monoplegia,  facial  paralysis,  aphasia,  and  disturbances 
of  sight,  hearing,  and  sensation  may  result  from  meningeal  hemorrhages. 
Various  psychoses,  such  as  melancholia  and  hallucinations,  have  been 
known  to  complicate  pertussis,  and  more  severe  forms  of  mental 
derangement,  such  as  imbecility  and  idiocy,  may  supervene. 

In  some  instances  emphysema  may  result  from  a  severe  paroxysm. 
Atelectasis,  bronchiectasis,  and  edema  of  the  glottis  are  among  the 
rarer  complications  in  the  respiratory  tract.     Pulmonary  affections 


.    PERTUSSIS  691 

are  by  far  the  most  serious.  Of  these  bronchopneumonia  is  responsible 
for  the  majority  of  deaths;  it  occurs  more  frequently  during  the  winter 
and  spring  months.  Miliary  tuberculosis  or  phthisis  may  also  be 
excited  by  an  attack  of  pertussis. 

Other  complications  may  occur,  such  as  pleurisy,  valvular  heart 
disease,  and  nephritis,  while  gastro-enteritis  is  not  an  uncommon 
sequel  in  infants,  and  may  terminate  fatally. 

Diagnosis. — The  characteristic  whoop  of  the  disease  renders  the 
diagnosis  easy,  although  it  must  be  borne  in  mind  that  there  are 
cases  in  which  this  is  absent.  If  the  disease  is  prevalent,  however, 
if  there  is  a  history  of  exposure,  and  the  cough  is  uninfluenced  by 
treatment,  the  disease  can  be  no  other  than  whooping-cough.  Partic- 
ularly is  this  true  if  there  is  occasional  vomiting  after  the  paroxysms 
of  coughing. 

The  chest  examination  in  the  catarrhal  stage  reveals,  as  a  rule,  only 
a  slight  bronchitis  to  account  for  the  severity  of  the  cough,  and  this  is 
quite  characteristic  of  pertussis,  although  it  is  scarcely  possible  to 
diagnose  the  disease  before  the  whoop  is  heard.  A  severe  cough, 
worse  at  night,  which  brings  on  vomiting,  and  is  unaccompanied  by 
fever,  is  almost  certainly  pertussis.  Leukocytosis  may  be  of  some 
value  in  doubtful  cases. 

Recent  experimental  researches  would  seem  to  indicate  that  the 
diagnosis  of  pertussis  may  be  made  at  any  stage  of  the  disease  by 
means  of  the  complement-fixation  test.  The  procedure  is  the  same 
as  for  other  complement-fix:ation  tests,  pure  cultures  of  the  Bordet- 
Gengou  bacillus  being  employed. 

Prognosis. — In  early  infancy,  especially  during  the  first  year,  whoop- 
ing-cough is  an  extremely  fatal  malady,  owing  to  the  serious  com- 
plications so  often  encountered.  The  mortality  has  been  estimated 
as  at  least  20  per  cent,  during  the  first  year,  and  most  of  the  deaths 
occur  in  bottle-fed  babies  who  also  sufi^er  from  gastro-enteritis,  and 
finally  succumb.  After  this  age,  the  percentage  of  deaths  decidedly 
decreases,  and  the  prognosis  depends  upon  the  previous  health  of  the 
child,  and  the  presence  or  absence  of  complications  or  of  constitutional 
diseases,  such  as  tuberculosis  or  rachitis. 

Children  aft'ected  during  the  summer  months  are  more  apt  to  escape 
that  much  dreaded  complication — bronchopneumonia — than  those 
attacked  during  the  winter  months.  Fifty  to  70  per  cent,  of  deaths 
occurring  during  whooping-cough  are  due  to  bronchopneumonia. 
Following  this  are  the  various  intestinal  disorders,  chief  and  most 
common  of  which  is  diarrhea.  Other  causes  of  death  are  convulsions, 
cerebral  hemorrhage,  asphyxia,  and  emphysema. 

According  to  Dr.  Paul  Luttinger,  of  the  Bureau  of  Laboratories, 
New  York  City,  the  highest  incidence  and  mortality — 56  per  cent. — 
have  been  observed  among  females,  the  incidence  and  mortality  in 
males  being  44  per  cent.  This  has  been  attributed  to  anatomical 
differences  in  the  construction  of  the  larynx,  and  is,  perhaps,  also  due 
to  a  nervous  system  which  is  more  susceptible  in  girls  than  in  boys. 


692  THE  SPECIFIC  INFECTIOUS  DISEASES 

The  influence  of  sex  is  apparent  at  all  ages,  and  it  would  appear  from 
our  present  knowledge  that  it  becomes  more  evident  the  older  the 
girls   are. 

It  is  difficult  to  state  positively  what  the  true  case  incidence  mortality 
is.  All  cases  of  pertussis  are  not  reported,  especially  the  mild  and 
atypical  ones.  The  law,  in  Pennsylvania,  placards  the  house,  but 
excludes  from  school  only  the  children  who  actually  have  the  disease, 
allowing  the  other  children  to  go  to  school  if  the}-  are  free  from  symp- 
toms. If  this  law  were  better  understood  by  physicians  and  the  laity, 
more  cases  would  undoubtedly  be  reported. 

The  true  case  mortality,  when  one  includes  the  mild  and  atypical 
cases,  is  certaintly  much  less  than  statistics  ordinarilv  indicate. 


Number  of  Deaths  in  Phil 

^DELPHIA- 

— Whooping- 

COUGH. 

Age  period. 

1911. 

1912. 

1913. 

1914. 

1915 

Under  one  year  . 

.      .        41 

53 

51 

135 

18 

1  to    2  years 

.      .        37 

18 

25 

74 

17 

2  to    5       " 

.      .        32 

22 

22 

45 

10 

5  to  10       " 

5 

6 

8 

10 

2 

10  to  15       " 

.      .         0 

0 

0 

1 

0 

15  to  20      " 

.       .          0 

1 

0 

0 

0 

All  ages 116      100      106     266     67 


Treatment. — Children  suffering  from  this  malady  should  be  promptly 
isolated  from  other  children  for  a  period  of  not  less  than  six  weeks, 
owing  to  the  fact  that  the  disease  is  invariably  contracted  by  direct 
contact.  Rest  in  bed  is  imperative,  in  cases  of  unusual  severity, 
together  with  an  abundance  of  fresh  air  day  and  night. 

The  treatment  of  pertussis  is  a  subject  which  has  always  absorbed 
a  large  degree  of  medical  attention,  and  the  mere  enumeration  of 
all  the  drugs,  inhalations,  and  cures  which  have  from  time  to  time 
been  brought  forward  would  consume  far  more  space  than  is  here 
possible.  I  will  not,  therefore,  attempt  to  mention  the  drugs  and  plans 
of  treatment  that  might  properly  be  considered  in  a  historical  sketch 
of  this  much-to-be-dreaded  disease,  but  will  call  attention  to  only  a 
few  of  the  drugs  and  methods  of  treatment  that  have  in  my  judgment 
stood  the  test  of  long  experience,  such  as  fresh  air,  careful  attention 
to  feeding  and  digestion,  local  applications  to  the  nasopharynx, 
inhalations,  belladonna,  antipyrin,  bromides,  codein,  trional,  heroin, 
and  chloral.  Among  the  newer  methods  of  treatment  are:  quinine 
given  intravenously  and  intramuscularly,  adrenalin,  suggestion,  and 
vaccine  treatment. 

As  pertussis  is  contagious  from  the  very  beginning  of  the  catarrhal 
stage  until  the  end  of  the  spasmodic  stage — a  period  of  about  ten 
weeks — it  is  important  that  children  free  from  the  disease  be  kept 
apart  from  those  who  have  it,  and  in  order  that  quarantine  be  effective 
all  unexposed  children  should,  if  possible,  be  sent  away  from  the  house 
during  the  entire  period  of  contagion.  This  applies  particularly  to 
infants,  in  whom  pertussis  is  associated  with  considerable  danger; 
and  all  children  who  are  not  robust  or  who  have  a  tendency  to  tuber- 


PERTUSSIS  ..  693 

eulosis  should  be  especially  protected.  A  child  with  pertussis  should 
not  be  allowed  to  attend  school,  and  quarantine  should  be  continued 
until  the  end  of  the  spasmodic  stage. 

All  children  with  pertussis  should  be  given  an  abundance  of  fresh 
air  and  should  be  kept  in  bed  if  their  temperature  is  100°  F.  or  higher. 
If  the  patient  is  sufficiently  ill  to  be  in  bed  the  windows  should  be 
open  day  and  night;  if  not  in  bed  the  child  should  spend  as  much 
time  as  possible  out  of  doors.  However,  as  excitement  and  violent 
exercise  increase  the  tendency  to  attacks,  an  effort  should  be  made 
to  keep  the  child  interested  and  amused  with  the  minimum  amount 
of  exertion  on  his  part.  An  acute  laryngitis  or  rhinitis  is,  however, 
not  benefited  by  cold  air;  for  such  cases  the  air  in  the  sick-room  must 
be  kept  fresh  but  not  cold.  Cold,  fresh  air  is  of  benefit  in  all  other 
pertussis  cases.  A  change  of  air,  especially  to  the  seashore,  is  often  of 
benefit,  and  a  change  from  a  raw,  damp  climate  to  a  warmer  and 
milder  one  is  often  followed  by  improvement. 

If  the  child  has  been  confined  to  bed  any  considerable  time  it  is 
of  advantage  to  remove  him  to  another  room  and  thoroughly  house- 
clean  the  room  before  returning  him  to  it.  Wards  where  pertussis 
patients  are  treated  should,  if  possible,  be  cleared  of  all  patients  and 
house-cleaned  and  fumigated  before  the  patients  return  to  them. 
Many  cases  of  whooping-cough  in  a  hospital  ward  suffer  with  mixed 
infections,  and  at  least  a  temporary  benefit  will  follow  their  removal 
to  a  recently  cleaned  and  fumigated  ward. 

All  children  with  pertussis  should  be  fed  in  small  quantities  and 
often,  and  the  younger  the  child  the  more  necessary  it  is  to  preserve 
its  strength  by  proper  attention  to  its  food  and  digestion.  If  a  child 
vomits  soon  after  receiving  nourishment,  it  should  be  given  another 
feeding  to  replace  the  one  vomited.  Gastro-intestinal  disorders  in 
the  young  child  suffering  with  pertussis  often  constitute  a  dangerous 
complication,  and  should  receive  early  and  careful  dietetic  and 
medicinal  treatment. 

Local  applications  to  the  nasopharynx,  if  made  early  in  the  disease — 
during  the  first  two  weeks — may  be  of  decided  value.  They  are  of 
assistance  only  when  the  infection  is  localized  in  the  upper  air  passages, 
as  in  rhinitis  and  pharyngitis.  At  this  period  an  application  of  2  per 
cent,  nitrate  of  silver  solution  to  the  nasopharynx  may,  by  producing 
death  of  the  superficial  mucous  membrane,  and,  possibly,  destroying 
some  of  the  specific  pertussis  bacilli,  tend  to  prevent  the  spread  of  the 
infection  to  the  deeper  respiratory  passages. 

Ochsenius,  of  Chemnitz^  has  recently  reported  107  children  treated 
by  this  method,  with  improvement  in  84  of  them.  He  makes  the 
application  every  second  day,  and  claims  that  eight  days  after  the 
beginning  of  the  treatment  the  number  of  paroxysms  is  slightly 
diminished  and  the  severity  of  the  attacks  decidedly  lessened,  and  by 
the  third  or  fourth  week  improvement  is  marked.     He  lays  special 

1  Therap.  der  Gegen.,  Berlin,  1913,  liv,  502-509. 


691  THE  SPECIFIC   INFECTIOUS  DISEASES 

stress  on  the  importance  of  using  the  nitrate  of  silver  solution  early 
in  the  disease,  when  the  infection  is  limited  to  the  upper  respiratory 
tract.  Phenol  (1  per  cent.)  has  also  been  used  successfully  as  a  local 
application.  It  should  be  employed  early  and  may  be  repeated  every 
second  day. 

Various  drugs  have  been  used  by  inhalation,  particularly  creosote 
and  carbolic  acid.  They  may  be  used  in  the  ordinary  inhaler  covering 
the  nose  and  mouth,  or  the  vapor  may  be  generated  in  the  room  of  the 
patient.  They  act  as  a  sedative  to  the  inflamed  mucous  membranes 
and,  at  least  in  some  degree,  as  a  local  antiseptic.  As  children  are 
especially  susceptible  to  carbolic  acid  poisoning,  the  urine  must  be 
closely  watched.  Chloroform  may  also  be  given  cautiously  by  the 
physician  when  the  paroxysms  are  especially  severe  and  frequent. 
When  the  spasm  of  the  glottis  is  unusually  severe,  intubation  may  be 
done  and  often  gives  relief. 

The  medicinal  treatment  of  pertussis  may,  for  convenience,  be 
divided  into  two  parts:  (1)  drugs  or  other  methods  that  per  se  have 
a  tendency  to  lessen  the  number  and  severity  of  the  paroxysms. 
(2)  drugs  or  other  methods  directed  to  the  treatment  of  the  com- 
plications of  pertussis.  To  the  first  an  unusual  amount  of  attention 
has  been  given;  to  the  second,  comparatively  little.  Among  the  drugs 
that  per  se  are  useful  in  pertussis  must  first  be  mentioned  belladonna. 
Personally,  I  prefer  using  the  tincture,  beginning  with  one  drop, 
three  times  a  day,  and  increasing  the  daily  quantity  by  one  or  two- drops 
until  mild  physiological  effects  of  the  drug  appear,  after  which  the 
dose  must  be  increased   very  cautiously. 

Antipyrin  is  a  useful  drug,  but  I  have  never  used  it  in  the  frequent 
doses  so  often  advised.  A  single  dose  at  bedtime,  or  a  morning 
and  evening  dose,  has  been,  in  my  experience,  as  much  as  it  was  wise 
to  employ.  To  a  child  of  two  years  I  would  give  2  or  3  grains  each 
night,   or  morning   and   night. 

Bromide  of  soda,  grains  v,  three  or  four  times  a  day,  to  a  child  of 
three  years,  is  often  of  benefit,  and  codein,  trional,  heroin,  and  chloral 
will  often  allay  the  cough  and  induce  sleep.  They  may  be  given  in  a 
single  dose  at  bedtime,  or,  if  necessary,  two  or  three  times  a  day. 
A  combination  of  quinine,  two  parts,  and  veronal,  one  part,  has  been 
used  successfully  by.  Professor  Winternitz,  of  Vienna.  He  claims 
distinct  improvement  in  26  out  of  30  children  in  whom  he  used  the 
combined  drugs,  but  believes  that  it  acts  only  as  long  as  given,  and  is 
not  a  cure.  During  its  administration  the  paroxysms  became  milder 
and  occurred  less  frequently;  there  was  less  vomiting,  and  the  appetite 
improved.  Frankel  and  Hauptmann^  also  advise  this  combination 
of  veronal  and  quinine.  The  dose  ordinarily  employed  for  a  child  of 
two  years  was  veronal,  ^  grain;  quinine,  1  grain,  repeated  three  or 
four  times  a  day,  according  to  the  eft'ect  produced.  They  do  not  advise 
its  use  in  children  under  six  months  of  age.     Soolman  and  Hatcher^ 

1  Med.  Klinik,  Berlin,  1912,  viii,  1871. 

2  Jour.  Am.  Med.  Assn.,  1908,  ii,  487.. 


PERTUSSIS  695 

report  favorable  results  from  a  combination  of  quinine,  grains  i-ij, 
ahd  bromide,  grains  i-ij,  repeated  three  or  four  times  a  day,  for  a  child 
two  years  of  age. 

Quinine  has  been  used  in  large  doses  and  when  so  given  may  reduce 
not  only  the  number,  but  also  the  severity  of  the  paroxysms.  It  is 
not  an  antispasmodic,  and  any  effect  it  produces  in  these  large  doses 
must  be  due  to  some  effect  on  the  causal  bacillus.  Lenzmann^  has 
reported  some  interesting  results  from  the  giving  of  quinine  intraven- 
ously and  hypodermically.  He  secured  very  prompt  and  positive 
results  from  doses  of  5  grains  injected  intravenously  every  second  day. 
He  claims  that  the  paroxysms  rapidly  disappear  and  that  the  treatment 
acts  like  a  charm.  Quinine  lactate,  10  grams;  saline  solution,  100 
grams,  of  which  2|  c.c,  warm,  is  injected  intravenously,  may  be 
similarly  used.  If  given  hypodermically  into  the  muscles  the  effect 
is  favorable,  but  not  as  prompt  nor  as  satisfactory  as  when  given 
intravenously. 

Hydroquinine  has  been  employed  both  intravenously  and  intra- 
muscularly, but  its  action  is  more  favorable  when  injected  into  the 
vein.  It  has  been  put  up  in  ampules,  the  dose  being  in  proportion  to 
the  age  of  the  child.  A  daily  dose  was  given  for  five  or  six  days,  then 
a  dose  every  second  day;  it  is  claimed  that  marked  improvement  was 
perceptible  after  the  first  week  of  treatment.  No  disagreeable  local  or 
constitutional  symptoms  followed  either  the  intravenous  or  muscular 
injections,  and,  as  so  much  is  claimed  for  this  treatment,  it  is  worthy 
of  more  extended  trial.  Hydroquinine  has  been  used  both  intravenously 
and  intramuscularly  as  a  prophylactic  with  satisfactory  results. 

Adrenalin  is  strongly  advised  in  the  treatment  of  pertussis  by 
Fletcher,^  and  since  the  publication  of  his  article  others  have  reported 
favorable  results  following  its  use.  Wm.  J.  Lord,^  when  all  other 
means  failed  in  a  very  delicate  child,  gave,  by  the  mouth,  SHI  of  a 
1  to  1000  adrenalin  solution  every  four  hours.  The  dose  was  soon 
reduced  to  three  times  a  day,  and  the  child  j-apidly  improved;  not 
only  the  number  of  the  paroxysms  became  less,  but  their  severity 
decidedly  diminished.  Carta  Mulas,*  who  had  read  Fletcher's  article, 
used  adrenalin  in  a  small  epidemic  of  pertussis.  He  treated  15  cases, 
giving  two  to  three  drops  of  a  1  to  1000  adrenalin  solution  every  two 
or  three  hours.  The  cough  and  vomiting  rapidly  diminished,  no  com- 
plications or  bad  effects  followed  the  treatment,  and  in  two  or  three 
weeks  the  patients  were  well.  He  claims  that  the  rapid  cure  of  these 
cases  prevented  the  spread  of  pertussis,  as  only  5  per  cent,  of  the 
infants  contracted  it.  In  his  opinion,  adrenalin  exerts  a  specific  action 
on  the  causal  agent  of  pertussis. 

Kilmer,  of  New  York  City,  has  devised  a  whooping-cough  belt 
which  supports  the  abdomen,  and  is  evidently  a  great  comfort  to  the 

1  Med.  Klinik,  Berlin,  1912,  viii,  1789. 

2  BriUsh  Med.  Jour.,  London,  1912,  ii,  1784. 

3  Ibid.,  1913,  ii,  122. 

4  Gaz.  d.  Osp.,  Milano,  1913,  xxxiv,  1295-1297. 


696  THE  SPECIFIC  INFECTIOUS  DISEASES 

patient,  for  children  who  have  once  worn  this  belt  insist  on  keeping 
it  on  during  the  paroxysmal  stages  of  the  disease,  and  like  it  to  be 
buckled  tight.  In  severe  cases  in  which  the  paroxysms  are  violent, 
a  plaster  bandage  may  be  applied  around  the  ribs  to  give  additional 
support.  Some  authorities  encircle  the  chest  with  strips  of  belladonna 
plaster.  If  these  supports  are  properly  applied  and  fit  snugly,  they 
often  modify  the  intensity  of  the  paroxysms  and,  to  a  great  extent, 
relieve  the  vomiting. 

Every  close  student  of  pertussis  must  be  impressed  with  the  psychic 
element  that  so  often  enters  into  the  disease,  especially  in  neurotic 
children.  If,  as  often  happens,  the  mother  and  those  who  are  brought 
in  contact  with  the  nervous  child  are  also  neurotic,  conditions  are 
favorable  for  the  development  of  marked  psychic  phenomena  in  this 
nervous  child  suffering  from  pertussis.  Given  a  neurotic  child 
in  whom  the  psychic  element  is  present,  and  suggestion  may  be 
advantageously  used  as  an  aid  to  treatment.  Oberholtzer,^  in  dis- 
cussing the  psychic  element  in  pertussis,  narrates  the  case  of  a  boy, 
aged  seven  years,  whose  nurse,  believing  the  paroxysms  were  largely 
induced  by  the  desire  of  the  boy  to  be  carried  in  her  arms,  refused  to 
carry  him  any  more.  His  paroxysms  ceased  and  he  made  a  prompt 
recovery.  His  little  sister  of  twenty  months  always  began  to  cough 
as  soon  as  the  boy  had  a  proxysm.  The  nurse  reproved  her  and  the 
paroxysms  of  cough  ceased.  One  day  while  taking  a  trip  on  the  lake, 
and  after  the  nurse  had  told  the  boy  that  if  a  paroxysm  threatened, 
they  w^ould  have  to  return  home,  his  cough  disappeared  for  four  hours. 

Hamburger^  also  calls  attention  to  this  psychic  element,  and  reports 
the  case  of  a  girl,  aged  three  and  one-half  years,  cured  by  suggestion. 
The  child  suffered  with  pertussis  for  five  weeks  and  was  cured  in  two 
days  by  the  faradic  current.  Hamburger  infers  that  in  this  case  the 
paroxysms  were  pure  neurosis  after  five  weeks — what  he  calls  a  "half- 
voluntary  reflex." 

Space  does  not  permit  me  to  discuss  the  treatment  of  the  com- 
plications of  pertussis,  but  several  cases  that  I  have  seen  this  winter 
deserve  passing  mention.  A  boy,  aged  thirteen  months,  w^ith  a  tuber- 
culous family  history  and  himself  tuberculous,  passed  successfully 
through  a  severe  case  of  pertussis  complicated  with  bronchopneumonia. 
In  the  stage  of  decline  he  became  more  and  more  drowsy,  lumbar 
puncture  was  performed,  and  a  clear  fluid  removed  in  which  the 
tubercle  bacillus  could  not  be  found,  and  a  guinea-pig  injected  with 
3  c.c.  of  this  fluid  failed  to  develop  tuberculosis.  There  had  never  been 
any  discharge  from  either  ear,  but  Dr.  MacCuen  Smith  obtained  a 
drop  or  two  of  fluid  by  swabbing  the  ear  with  cotton.  Pus  was  obtained 
from  both  ears  by  puncturing  the  drums;  the  day  following,  a  double 
mastoid  operation  disclosed  a  well-advanced  double  mastoiditis  with 
secondary  otitic  meningitis.  The  temperature  had  been  normal  for 
ten  days  before  the  operation.     We  all,  of  course,  appreciate  how 

1  Corr.  Blatt  f.  Schweizer  Aerzte,  December  20,  1912. 

2  Wien.  klin.  Wchnschr.,  1913,  xxvi,  1869. 


PERTUSSIS  697 

latent  mastoiditis  may  be  in  a  child,  but  with  no  local  evidence  of 
mastoid  disease,  no  discharge  from  the  ear,  and  no  fever,  the  condition 
is  easily  overlooked. 

Another  case  of  interest  was  the  seven-year-old  son  of  Dr.  C,  of 
Philadelphia,  who  during  an  attack  of  pertussis  had  an  unusually 
severe  paroxysm  on  February  15.  The  next  morning  he  had  fever  and 
vomiting.  Vision  continued  to  decline  until  March  13,  when  vision 
was  found  to  be:  left,  11/200;  right,  20/100.  The  disks  are  pale;  retinal 
arteries  reduced  in  size;  field  of  view  is  concentrically  contracted. 
Previous  high-grade  double  optic  neuritis  (choked  disk).  At  present, 
total  secondary  atrophy.  Disseminated  choroiditis,  both  eyes. 
Divergence.  Vision  reduced  to  light  perception.  Pupils  moderate  in 
size  and  no  reaction.  Under  ethyl  chloride  narcosis,  pupils  contract 
ad  maximum.  Diagnosis:  hemorrhage  into  the  sheath  of  nerve  at  the 
optic  chiasm.  These  two  cases  illustrate  the  necessity  of  a  correct 
diagnosis  of  complications  in  order  properly  to  carry  out  appropriate 
treatment. 

The  Vaccine  Treatment. — I  was  the  first  to  try  this  method  of 
treatment  and  have  carefully  read  the  report  of  all  cases  treated  by 
this  method  since  the  publication  of  my  paper  in  January,  1912.  A 
large  number  of  articles  have  appeared  upon  vaccine  treatment,  and 
from  the  close  study  of  my  own  series,  as  well  as  many  cases  seen  in 
consultation  where  the  vaccine  treatment  has  been  used,  since  the 
publication  of  my  paper,  I  am  convinced  that  it  is  a  distinct  addition 
to  our  treatment,  and  is  also  of  more  or  less  use  as  a  prophylactic. 
In  a  case  of  moderate  severity  in  either  an  infant  or  an  older  child, 
when  the  number  of  the  paroxysms  is  small  and  of  a  mild  character, 
the  vaccine  treatment  is  not  necessary  but  it  is  often  of  distinct  benefit 
in  the  severe  cases,  in  children  of  all  ages,  and  its  influence  as  a  prophyl- 
actic, especially  where  infants  have  been  exposed,  or  where  a  frail  or 
possibly  tuberculous  child  has  been  infected  with  the  pertussis  bacillus, 
should  be  carefully  investigated,  and  its  proplylactic  power  tested. 
There  seems  to  be  a  growing  tendency  to  treat  pertussis  with  a  mixed 
vaccine. 

In  connection  with  the  mortality  tables  of  typhoid  fever,  diphtheria, 
scarlet  fever,  measles,  and  whooping-cough,  showing  the  number  of 
deaths  in  Philadelphia  during  the  five  years,  1911  to  1915,  inclusive, 
the  f  oho  wing  table  (No.  1)  shows  the  percentage  of  deaths  to  the  total 
number  of  cases  of  these  diseases.  Table  Xo.  2  may  be  of  special 
interest;  it  shows  the  number  of  deaths  in  Pennsylvania  from  the 
above  diseases  during  the  years  1909-1912,  inclusive,  in  children 
under  one  year  of  age,  in  children  under  five  years  of  age,  also  at  all 
ages,  as  well  as  the  total  mortality  in  Pennsylvania  from  all  diseases 
during  these  years.  Table  Xo.  3  shows  the  mortality  in  Pennsyl- 
vania, during  the  years  1911  and  1912,  from  the  diseases  tabulated, 
embracing  the  number  of  deaths  at  all  ages,  also  the  mortality  in  chil- 
dren under  five  years  of  age. 


698 


THE  SPECIFIC  INFECTIOUS  DISEASES 


Table  1 . — Table  Showing  Percentage  of  Deaths  to  Total  Number  of  Cases 

OF  Measles,  Diphtheria,  Scarlet  Fever,  Whooping-cough,  and  Typhoib 

Fever  in  Philadelphia  from  1911  to  1915,  Inclusive. 


Number  of  cases. 

Total 
No.  of 

Total 

ISTn    nf 

Percentage 
of  deaths 

1911.        1912. 

:              i 

1913. 

1914.         1915. 

cases      ,    deaths 
in  5  years,  in  5  years. 

to  total 
No.  of  cases 
in  5  years. 

Measles  .... 
Diphtheria    . 
Scarlet  fever 
Whooping-cough 
Typhoid  fever    . 

11,640 
3,792 
1,928 
1,410 
1,382 

2,279 
3,080 
2,872 
1,369 
1,514 

15,611 
2,623 
3,400 
1,438 
1,698 

7,096 
2,610 
1,944 
4,1.52 
793 

14,089 
2,615 
1,072 
1,092 

787 

Total 

50,715             798 

14,720          1,741 

11,216             608 

9,461     1         655 

6,174             911 

1.5  + 
11.8 

5.4 

7.0 
14.7 

92,286 

4,713 

Table  2. 


State  of  Pennsylvania. 
Total  mortality,  1909,  from  all  diseases  . 
"  "    typhoid  fever 

"  "    diphtheria 

"  "    scarlet  fever 

"         "    measles    . 

"    whooping-cough 

1910,  from  all  diseases  . 
'■  typhoid  fever 
"  diphtheria  . 
"    scarlet  fever 

"  "     measles    . 

"    whooping-cough 

1911,  from  all  diseases    . 
"  "    typhoid  fever 

"    diphtheria 
"  "    scarlet  fever 

"    measles    . 
"    whooping-cough 

1912,  from  all  diseases    . 
"  "    typhoid  fever 

"    diphtheria 
"  "    scarlet  fever 

"  "    measles    . 

"    whooping-cough 


At  all 
ages. 

111,062 

1,712 

2,002 

1,216 

1,060 

910 

119,815 

1,892 

2,235 

1,094 

1,237 

1,114 

111,292 

1,716 

2,111 

749 

804 

998 

111,842 

1,310 

2,042 

552 

845 

809 


Under 
one  year. 

25,638 

8 

139 

72 

286 

500 

28,377 

3 

178 

64 

306 

581 

24,195 

4 

122 

46 

202 

567 

24,110 

8 

146 

34 

202 

476 


Under 
five  years. 

36,216 

87 

1,350 

754 

934 

870 

40,495 

77 

1,443 

657 

1,083 

1,068 

33,788 

66 

1,346 

460 

704 

960 

33,468 

51 

1,371 

337 

735 

777 


Table  3. 


1911. 

Mortality  in  State  of  Pennsylvania.         . , 

All  ages.        Under  5  years. 
Acute  anterior  poliomyelitis     ...  93  61 

Con^allsions  of  infants         ....      1062 
Diarrhea  and  enteritis  (infantile)        .      8156 

(Under  2  yrs.) 

Rickets 69  63 

Congenital  malformations        .      .       .      1345  1319 

of  heart     .        881  862 

Injuries  at  birth 552  552 

Congenital      debility,      icterus,      and 

sclerema 5942  5942 

Diseases  of  spleen 14  2 

Hernia,  intestinal  obstruction        .       .        855  174 

Pneumonia 3573  1525 


1912. 


All  ages 

116 

960 

7469 

(Under  2  yrs.) 

90 

1389 

877 

593 

6420 

10 

930 

7130 


Under  5  years. 

78 


87 

1368 

867 

593 

6420 

1 

191 

2352 


MUMPS.  699 

MUMPS  (EPIDEMIC  PAROTITIS). 

Mumps  is  an  infectious  disease,  characterized  by  swelling  of  the 
salivary  glands,  particularly  the  parotid  gland,  together  with  mild 
constitutional  symptoms. 

Etiology. — It  has  not  been  proven  to  be  due  to  any  one  type  of 
organism,  but  Catlin  and  Laveran  have  isolated  from  the  blood  and 
glandular  lymph  of  the  parotids  and  testes  a  diplococcus  which  pro- 
duced parotitis  in  dogs  and  monkeys  when  injected  into  Steno's 
duct.  An  intracellular  diplococcus  has  also  been  isolated  from  Steno's 
duct,  and  it  is  generally  believed  that  the  infection  enters  the  parotid 
from  the  mouth  by  way  of  this  duct. 

The  mode  of  infection  is  usually  by  direct  contact,  though  it  is 
possible  to  convey  the  infection  by  a  third  person  or  by  clothing.  It 
occurs  endemically  in  large  cities,  particularly  in  spring  and  autumn. 
It  is  more  common  in  boys  than  in  girls.  Children  between  the  ages 
of  three  and  ten  years  are  more  susceptible  than  young  infants  and 
adults.  Owing  to  the  fact  that  the  disease  is  communicable  for  several 
days  after  the  subsidence  of  the  swelling,  such  children  should  be 
isolated  for  a  period  of  at  least  three  weeks  from  the  date  of  onset. 
The  period  of  incubation  is  from  ten  days  to  three  weeks,  and  during 
this  time  there  are  rarely  any  symptoms  of  the  affection. 

Morbid  Anatomy. — Owing  to  the  trivial  nature  of  this  disease,  there 
has  been  little  opportunity  to  note  the  pathological  changes  which  take 
place ;  but  there  is,  as  a  rule,  simply  a  serous  infiltration  which  usually 
ends  in  resolution.    Suppuration  is  very  rare. 

Symptoms. — There  is  usually  a  prodromal  period  during  which 
the  child  is  chilly  and  may  vomit;  following  this  the  acute  symptoms 
appear,  varying  in  character  and  intensity  according  to  the  severity 
of  the  attack.  The  onset  is  usually  marked  by  fever  ranging  from 
100°  to  101°  F.,  headache,  anorexia,  vomiting,  and  pains  in  the  back 
and  legs.  Pain  on  swallowing  or  moving  the  jaw  may  be  the  first 
objective  symptom,  and  the  child  complains  of  pain  beneath  the  ear. 
A  slight  swelling  begins,  usually  on  one  side,  which  reaches  its  height 
on  the  second  or  third  day,  remains  stationary  for  two  or  three  days, 
and  then  gradually  subsides.  The  swelling  causes  the  lobe  of  the 
ear  to  be  lifted  and  passes  forward  in  front  of  the  ear  and  backward 
to  the  sternomastoid  muscle.  The  other  salivary  glands,  the  sub- 
maxillary and  sublingual,  are  often  not  involved  or  they  may  at  the 
same  time  show  evidence  of  swelling,  or  may  not  become  enlarged 
until  after  the  parotid  swelling  has  completely  disappeared.  More 
frequently  both  parotid  glands  become  involved,  but  not  simultane- 
ously; the  inflammation  appears  in  one,  and  the  maximum  swelling 
is  reached  in  forty-eight  hours,  after  which  the  other  side  becomes 
involved,  and  swells  with  equal  rapidity.  When  one  alone  is  affected, 
it  is  more  often  the  left  than  the  right.  During  the  height  of  the  disease 
the  mouth  becomes  dry,  the  salivary  secretions  are  diminished,  and 
there  is  excessive  pain  on  swallowing.     Mastication  is  both  difficult 


TOO  THE  SPECIFIC  INFECTIOUS  DISEASES 

and  painful,  and  in  extreme  cases  it  may  be  almost  impossible  to  open 
the  mouth  because  the  parts  are  so  tense  and  swollen.  In  young  infants 
there  is  drooling.  There  may  be  earache,  otitis  media,  and  frequently 
also  slight  impairment  of  hearing.  In  the  more  severe  cases  there 
may  be  high  fever,  ranging  from  103°  to  104°  F.,  delirium  and  marked 
prostration.  Relapses  are  rare,  but  cases  of  recurrent  mumps  have 
been  reported  which  persisted  for  six  weeks. 

Diagnosis. — The  diagnosis  is  usually  easy,  though  the  disease  may 
be  confused  with  acute  swelling  of  the  cervical  lymph  nodes.  The 
latter  is  usually  behind  the  jaw,  and  does  not  extend  to  the  face.  In 
swelling  of  the  parotid  gland,  the  lobe  of  the  ear  on  the  affected  side 
becomes  elevated,  and  occupies  the  centre  of  the  tumefaction,  the 
swelling  extending  in  front  of  and  below  the  ear.  The  rapidity  of  the 
swelling  and  its  short  duration  are  characteristic  of  mumps.  Inflam- 
mation of  the  parotid  is  usually,  but  not  invariably,  due  to  mumps; 
a  history  of  other  cases  in  the  vicinity,  is  additional  evidence  in  favor 
of  true  mumps. 

Complications. — In  childhood  complications  are  rare,  but  in  puberty 
orchitis  may  occur,  usually  making  its  appearance  between  the  second 
and  third  weeks  of  the  disease,  and  occurring  most  frequently  in  those 
who  are  allowed  to  be  up  and  about.  Either  one  or  both  testicles 
may  become  involved  and  the  swelling  is  marked.  Usually  the  testicle 
proper  and  not  the  epididymis  is  affected;  but  occasionally  there  may 
be  acute  epididymitis,  acute  hydrocele,  edema  of  the  scrotum,  or 
inflammation  of  the  spermatic  cord  and  inguinal  glands.  Frequently 
it  is  accompanied  by  fever  and  chills,  and  the  testes  are  painful  and 
heavy. 

The  acute  symptoms  continue  for  from  three  to  seven  days,  though 
frequently  the  testicle  remains  enlarged  for  some  time  afterward, 
and  the  swelling  persists  even  longer  when  the  parotitis  is  bilateral. 
x\trophy  of  the  testes  with  resulting  sterility  has  been  reported  as 
following  mumps. 

In  some  cases  the  urine  contains  a  trace  of  albumin.  Urination  may 
be  painful,  and  there  may  be  a  urethral  discharge.  In  females  there 
may  be  congestion  of  the  breasts,  ovaries,  and  labia  majora,  though 
such  complications  are  not  at  all  common. 

The  thyroid  gland  may  show  some  enlargement  during  the  attack. 
Delirium  and  high  fever  are  occasionally  observed,  coma  may  appear, 
more  rarely  there  is  acute  mania,  and,  in  exceptional  instances,  insanity. 
Hemiplegia  may  occur,  and  in  rare  cases  meningitis.  Suppuration 
of  the  parotid  gland  is  rare,  and  when  it  occurs  is  probably  the  result 
of  a  mixed  infection. 

There  may  be  disturbances  of  the  special  senses,  such  as  deafness 
and  optic  neuritis.  Nephritis  has  in  some  cases  followed  an  attack. 
Pneumonia,  endocarditis,  and  pericarditis  occur  in  rare  instances. 
As  a  rule  complications. do  not  appear  until  after  the  parotitis  has 
subsided.  Parotitis  itself  may  be  a  complication  of  pneumonia, 
influenza,  measles,  varicella,  or  t^^jhoid  fever. 


INFLUENZA  701 

Course  and  Prognosis. — In  the  vast  majority  of  instances  mumps  is  a 
mild  disease,  from  which  complete  recovery  takes  place  in  a  few  days, 
and  the  disease  generally  runs  its  course  in  a  week  or  ten  days.  Severe 
cases  are  rare;  if  uncomplicated,  the  prognosis  is  very  favorable.  When 
such  complications  as  edema  of  the  glottis,  suppuration  of  the  parotid, 
or  meningitis  occur,  the  outlook  becomes  serious;  but  involvement  of 
the  testicles  or  ovaries  and  of  the  mammary  glands,  while  painful,  is. 
rarely  dangerous. 

Treatment. — Usually  little  or  no  treatment  is  necessary.  The  patient 
should  stay  in  bed  for  at  least  one  week.  The  bowels  can  be  opened 
freely  by  an  initial  dose  of  1  to  3  drams  of  castor  oil,  after  which  the 
aromatic  syrup  of  rhubarb,  1  to  2  drams,  or  the  aromatic  fiuidextract 
of  cascara  sagrada,  20  to  40  drops,  may  be  administered  whenever 
necessary.  The  patient  should  be  kept  upon  liquid  diet  for  a  week. 
If  the  fever  is  high,  5  to  10  drops  of  sweet  spirits  of  nitre  may  be  given 
every  three  hours,  or  the  temperature  may  be  reduced  by  sponging 
the  child  in  water  at  a  temperature  of  75°  to  85°  F.  Hexamethyl- 
enamin  should  be  given  in  1-  to  2-grain  doses,  three  times  a  day. 

If  pain  is  severe,  1  to  2  grains  of  Dover's  powder  may  be  combined 
with  3  grains  of  salol  or  1  grain  of  phenacetin,  and  administered  every 
four  hours  until  the  child  is  relieved. 

It  is  advisable  to  keep  these  children  warm,  and  to  prevent  any 
chilling  of  the  body  throughout  the  whole  course  of  the  disease,  since 
this  will  expedite  recovery,  and  also  because  it  is  believed  that  com- 
plications may  be  induced  by  sudden  chills. 

Locally  either  cold  or  hot  applications  may  be  used  on  the  gland; 
usually  the  latter  are  more  agreeable;  they  should  be  covered  with  a 
pad  of  cotton  wadding,  and  over  this  oiled  silk.  Relief  will  often  be 
afforded  by  anointing  the  gland  with  some  simple  ointment,  such  as 
cold  cream. 

For  severe  pain  warm  oil  of  hyoscyamus  may  be  applied  twice  daily, 
or  25  per  cent,  ichthyol,  or  such  remedies  as  witch  hazel,  lead-water 
and  laudanum,  or  menthol  may  be  employed  locally.  The  mouth 
should  be  frequently  cleansed  with  liquor  alkalinus  antisepticus, 
25  per  cent,  dilution,  in  order  to  prevent  infection  of  the  gland  through 
the  duct.  Children  suffering  with  mumps  should  be  isolated  and  kept 
apart  from  other  children  for  a  period  of  not  less  than  three  weeks. 

Should  orchitis  develop,  rest  in  bed,  together  with  support  of  the 
affected  testicle  with  cotton-wool  and  adhesive  straps,  will  usually 
suffice. 

INFLUENZA  (LA  GRIPPE:  CATARRHAL  FEVER). 

Influenza  is  an  acute  infectious  disease  characterized  by  a  catarrhal 
inflammation  of  the  mucous  membrane,  particularly  of  the  respiratory 
tract,  together  with  fever,  muscular  pain,  and  marked  prostration. 

Etiology. — The  bacillus  of  Pfeiffer,  discovered  in  1892,  is  found  in 
the  sputum  and  nasal  discharges.    It  is  0.8  to  1  micron  in  length,  and 


702  THE  SPECIFIC  INFECTIOUS" DISEASES 

0.1  to  0.2  micron  in  breadth.  In  glycerin  agar  it  forms  colonies,  which, 
under  the  microscope,  appear  as  clear,  separate  drops.  They  are  best 
stained  by  hot  Loeffler  methylene  blue  solution,  or  dilute  solution  of 
Ziehl-Xeelson  carbol-fuchsin.  The  bacillus  is  easily  transmitted  from 
one  individual  to  another,  because  of  its  presence  in  the  sputum  and 
nasal  discharges.  Other  organisms  associated  with  the  bacillus  of 
Pfeiffer  are  the  Streptococcus  and  Diplococcus  pneumoniae. 

Influenza  occurs  epidemically,  but  after  epidemics  may  remain 
endemically  for  some  time,  although  in  the  majority  of  endemic  cases 
of  influenza  it  is  impossible  to  isolate  the  Pfeiffer  bacillus.  The  diplo- 
coccus of  Frankel,  however,  is  quite  commonly  found  in  these  cases, 
therefore  it  is  often  called  pneumococcus  grippe.  Epidemics  usually 
occur  during  the  winter  and  spring. 

The  disease  also  appears  in  pandemics.  This  form  is  not  as  common 
in  children  as  in  adults,  but  the  endemic  form  of  influenza,  which  is 
encountered  at  all  seasons  of  the  year,  and  the  development  of  which  is 
favored  by  sudden  and  great  changes  in  temperature,  is  very  prone 
to  attack  children.  The  disease  is  rather  uncommon  in  infants,  but 
children  between  the  ages  of  two  and  ten  are  very  apt  to  contract  it. 
One  attack  does  not  confer  immunity  against  a  second,  and  some 
children  have  it  every  winter.  Among  the  predisposing  factors  in 
the  endemic  form  of  influenza  are  exposure  to  cold  and  lowered  vitality 
from  malnutrition,  exhausting  illness,  or  other  debilitating  influences. 

The  period  of  incubation  is  supposedly  short,  ranging  from  two  to 
seven  days.  The  chief  complications  are  pneumonia,  pleurisy,  and 
endocarditis. 

Two  types  of  influenza  are  recognized:  ejndemic  influenza  vera, 
caused  by  the  bacillus  of  Pfeiffer,  and  endemic  influenza  vera,  which 
appears  for  several  successive  years  after  a  pandemic. 

Morbid  Anatomy. — Our  present  knowledge  of  the  pathological 
changes  caused  by  influenza  is  very  scant,  for  whatever  alterations  are 
produced  by  this  disease  promptly  disappear  at  death.  There  is, 
however,  an  inflammation  of  the  mucous  membrane  of  the  upper 
respirator}^  tract,  and  in  severe  cases  the  trachea,  bronchi,  and  peri- 
bronchial tissues'  may  also  be  affected.  The  remaining  pathological 
changes  are  due  to  the  complications,  such  as  bronchopneumonia, 
otitis  media,  meningitis,  and  empyema.  In  infants  there  may  be 
catarrhal  inflammatory  changes  in  the  mucous  membrane  along  the 
gastro-intestinal  tract. 

Symptoms. — The  symptoms  of  influenza  in  children  vary  greatly, 
according  to  the  severity  of  the  attack.  If  mild,  the  onset  is  usually 
sudden,  and  the  attack  lasts  about  a  week.  Coryza,  sneezing,  and 
watering  of  the  eyes  are  usually  the  first  symptoms  to  make  their 
appearance,  and  these  are  followed  by  chills,  and  coughing  with 
profuse  expectoration.  The  throat  and  nares  are  red  and  injected,  and 
the  tonsils  are  frequently  covered  with  mucus,  and  studded  with  a 
yellowish  deposit.  The  cough  is  loud,  harsh,  painful,  and  sometimes 
very  persistent. 


INFLUENZA  703 

Muscular  pain  is  more  or  less  constant,  and  may  often  be  the 
first  symptom  of  the  illness,  manifesting  itself  in  the  back,  extremities, 
and  head,  so  that  the  child  cries  with  pain  when  picked  up  or  moved 
about.  Vomiting  may  occur.  The  temperature  range  is  from  101° 
to  103°  F.  There  is  usually  associated  pharyngitis  and  bronchitis, 
and  prostration  is  always  quite  marked.  In  infants  early  involvement 
of  the  gastro-intestinal  tract  is  shown  by  green  stools,  diarrhea,  loss 
of  appetite  for  breast  or  bottle,  and  colicky  pains  in  the  abdomen. 
Older  children  become  nauseated  and  constipated,  and  complain  of 
epigastric  pain. 

In  the  more  severe  types  of  influenza  the  onset  may  be  extremely 
sudden,  and  prostration  great.  Fever,  though  mild  at  first,  may  run 
exceedingly  high,  from  102°  to  105°  F.  and  even  106°  F.  At  this 
time  delirium  may  occur,  and  nervous  symptoms  become  prominent. 
The  child  usually  lies  in  a  drowsy,  stuporous  state,  and  although 
convulsions  are  rare,  musclar  twitchings  are  not  uncommon.  The  pulse 
rate  is  usually  accelerated,  and  corresponds  with  the  degree  of  tempera- 
ture. 

In  children  the  attack  may  be  preceded  by  severe  vomiting,  and 
sometimes  diarrhea;  but  the  symptoms  and  physical  signs  are  not  as 
severe  as  one  would  expect  with  the  degree  of  fever,  although  pros- 
tration is  profound.  Follicular  tonsillitis  frequently  accompanies 
this  class  of  cases,  and  pneumonia  is  a  common  complication.  The 
moderately  severe  cases  terminate  in  six  to  ten  days,  but  occasionally 
influenza  assumes  a  chronic  form,  in  which  the  temperature  and  other 
symptoms  persist  for  several  weeks. 

In  endemic  grippe,  especially,  there  is  usually  a  slight  trace  of 
albumin  in  the  urine,  and  the  kidneys  may  become  involved,  actual 
nephritis  being  indicated  by  a  decrease  in  the  quantity  of  the  urine, 
and  the  presence  of  blood  and  casts.  There  is  no  edema,  but  the 
persistence  of  albuminuria  for  w^eks  and  months  denotes  a  low-grade 
nephritis. 

In  very  severe  cases  of  influenza,  a  bacillus  may  be  found  in  the 
blood  stream,  and  meningitis  and  arthritis  are  not  infrequent  accom- 
paniments. According  to  the  predominating  symptoms,  the  disease 
in  the  adult  is  classified  as  respiratory,  nervous,  gastro-intestinal,  or 
febrile  influenza;  but  in  the  child  this  distinction  is  not  quite  so 
definite  for  the  symptoms  are  often  irregular.  In  some  children  the 
gastro-intestinal,  respiratory,  and  nervous  forms  may  occur  one  after 
the  other. 

Resjyiratory  Form. — In  the  respiratory  type  the  entire  tract  becomes 
the  seat  of  the  disease.  The  onset  is  marked  by  coryza  and  evidences 
of  acute  catarrhal  fever.  In  some  cases  bronchitis  follows  the  catarrhal 
symptoms,  there  is  a  steady  increase  in  the  fever,  delirium  may  appear, 
together  with  profound  prostration.  Pharyngitis,  tonsillitis,  and 
laryngitis  are  prominent  features  of  the  respiratory  form  of  influenza, 
and  latent  pulmonary  tuberculosis  may  again  become  active  in  con- 
sequence of  the  attack. 


704  THE  SPECIFIC  INFECTIOUS  DISEASES 

The  expectoration  is  copious,  and  contaias  masses  of  purulent 
material;  sometimes  the  sputum  may  be  bloody  and  of  a  dark  red 
color.  The  most  serious  complication  is  pneumonia,  which  is  most 
frequently  lobular  in  type.  It  may  set  in  after  several  days  of  severe 
bronchitis  and  high  fever,  the  smallest  bronchi  gradually  becoming 
involved,  or  it  may  develop  suddenly.  In  the  majority  of  cases 
pneumonia  is  due  to  the  pneumococcus,  and  clears  up  readily,  but  in 
some  instances  it  rapidly  proves  fatal.  The  outcome  depends  to  a 
great  extent  upon  the  virulence  of  the  organism,  and  the  resistance  and 
vitality  of  the  child.    Pleurisy  may  occur,  but  is  rare. 

Nervous  Form. — This  type  is  marked  by  the  absence  of  catarrhal 
symptoms,  and  manifests  itself  by  pains  in  the  back,  chest,  and  extremi- 
ties, intense  headache,  and  extreme  prostration.  These  children  are 
very  irritable  and  restless,  but  may  become  stuporous.  Occasionally 
convulsions  occur,  but  severe  nervous  manifestations  are  noted  only 
in  the  worst  forms  of  influenza.  Rigidity  of  the  muscles  of  the  neck, 
muscular  twitchings,  paresthesia,  and  dizziness  may  be  observed. 
Many  cases  in  which  nervous  symptoms  are  conspicuous  are  accom- 
panied by  pneumonia.  The  chief  complications  are  meningitis  and 
encephalitis,  but,  in  fact,  almost  any  type  of  nervous  disease  may 
complicate  an  attack  of  influenza. 

Gastro-intestinal  Form. — In  this  type  nausea  and  vomiting  pre- 
dominate, together  with  abdominal  pain  and  diarrhea,  all  of  which 
have  a  tendency  to  cause  collapse.  Malnutrition  is  severe  and, 
together  with  the  extreme  prostration  which  accompanies  grippe, 
results  in  exhaustion  and  emaciation  which  are  often  the  forerunners 
of  collapse.  Gastro-intestinal  symptoms  usually  predominate  in  very 
young  children,  and  in  infants  there  may  be  enlargement  of  the  spleen. 

Febrile  Form. — Here  fever  may  be  the  only  clinical  manifestation 
of  the  disease,  and  may  be  accompanied  by  chills,  and  be  remittent 
in  type;  or,  again,  the  fever  may  be  continuous,  and  closely  resemble 
typhoid  fever. 

Diagnosis. — Epidemic  grippe  is,  in  the  majority  of  cases,  easily 
diagnosed,  but  mild  sporadic  cases  may  present  some  difficulty  until 
carefully  studied.  The  profound  prostration  which  is  out  of  all 
proportion  to  the  other  clinical  manifestations,  together  with  the 
suddenness  of  onset  and  short  duration  of  the  fever,  will  usually  point 
to  the  diagnosis. 

The  nervous  symptoms  may  arouse  a  suspicion  of  meningitis,  but 
true  symptoms  and  signs  of  meningeal  inflammation  are  lacking; 
and  the  onset  of  pneumonia  in  this  class  of  cases  is  very  significant 
of  grippe. 

In  rare  cases  influenzal  meningitis  may  be  present  and  can  be 
demonstrated  by  examination  of  the  cerebrospinal  fluid  which  contains 
the  bacilli.  Pneumococcic  and  cerebrospinal  meningitis  are,  to  a  great 
extent,  differentiated  from  the  influenzal  type  by  the  bacteriological 
findings,  for  the  symptoms  are  not  widely  difterent. 

The  high  fever  and  cough  with  a  history  of  chills  may   simulate 


INFLUENZA  705 

pneumonia,  but  careful  examination  of  the  chest  will  exclude  this, 
except  when  pneumonia  is  present  as  a  complication.  At  the  onset 
of  influenza  both  scarlet  fever  and  measles  may  be  simulated  by  the 
pharyngitis,  coryza,  injected  conjunctiva,  and  bronchitis,  and  in  these 
cases  the  differential  diagnosis  is  occasionally  rendered  even  more 
difficult  by  the  appearance  of  a  rash  on  the  skin.  An  accurate  history 
and  careful  study  of  such  cases  for  two  or  three  days  will  generally 
clear  up  the  diagnosis. 

In  the  subacute  type  of  influenza  the  symptoms  may  to  some 
extent  resemble  those  of  typhoid  fever,  and  this  is  especially  the  case 
in  prolonged  attacks  with  continued  fever,  but  the  Widal  reaction  will 
be  found  negative,  there  are  no  rose  spots,  nor  is  there  any  marked 
enlargement  of  the  spleen. 

The  presence  of  the  influenza  bacillus  in  the  sputum  may  be  deter- 
mined microscopically  early  in  the  disease,  but  a  bacteriological  diag- 
nosis of  influenza,  while  very  valuable,  is  too  difficult  to  b^  resorted 
to  in  most  cases. 

Complications. — Pneumonia  is  by  far  the  most  serious  complication 
of  influenza,  and  may  be  associated  with  pleurisy  and  empyema. 
Endocarditis  and  pericarditis,  together  with  irregularity  of  the  heart — 
tachycardia  and  bradycardia — may  also  set  in,  and  meningitis  and 
encephalitis  are  sometimes  sequels.  Influenzal  meningitis  is  marked 
by  symptoms  of  meningeal  inflammation;  the  cerebrospinal  fluid 
is  cloudy,  and  contains  an  increased  number  of  polynuclear  cells. 
Upon  microscopic  examination  of  the  cerebrospinal  fluid  the  bacilli 
are  seen  to  be  both  intracellular  and  extracellular.  This  complication 
usually  results  in  death.  Acute  otitis  media  is  a  frequent  complication, 
and  may  result  in  mastoiditis  and  sinus  thrombosis.  Phlegmasia  alba 
dolens,  caused  by  venous  thrombosis,  has  occurred  in  several  instances. 
Cervical  adenitis  with  jnvolvement  of  the  parotid  and  submaxillary 
glands  is  not  uncommon. 

Skin  rashes  may  appear  during  the  course  of  the  disease,  although 
no  one  eruption  is  characteristic  of  influenza.  Among  the  various 
skin  lesions  which  may  be  noted  are  herpes  facialis,  herpes  zoster, 
erythema  papulatum,  urticaria,  and  a  scarlatiniform  erythema  which, 
to  a  certain  extent^  resembles  the  rash  of  both  measles  and  scarlet 
fever.  Secondary  anemia  usually  follows  an  attack  of  influenza,  and 
some  observers  have  noted  an  increase  in  the  number  of  cases  of 
appendicitis  during  epidemics  of  influenza. 

Cystitis  frequently  follows  grippe,  especially  in  little  girls,  and 
influenza  may  either  give  rise  to  rheumatic  symptoms  or  cause  an 
acute  exacerbation  of  rheumatism  in  children  who  already  suffer  from 
this  disease.  Influenza  has  a  tendency  to  stir  into  activity  any  latent 
form  of  disease;  this  is  particularly  true  of  latent  tuberculosis. 

Prognosis. — The  prognosis  is  usually  favorable,  provided  the  patient 

does  not  take  cold  during  the  attack,  and  thus  bring  on  that  dangerous 

sequel,  pneumonia,  as  well  as  other  complications.    In  infants  who  have 

influenza  there  is  often  serious  involvement  of  the  intestinal  tract, 

45 


706  THE  SPECIFIC  INFECTIOUS  DISEASES 

and  as  pneumonia  is  a  common  complication  in  the  younger  child, 
the  prognosis  is  more  serious  in  infants  and  very  young  children  than 
it  is  in  later  childhood.  Death  may  also  be  the  result  of  toxemia  and 
exhaustion,  especially  when  a  severe  attack  of  influenza  occurs  in  a 
child  whose  general  health  is  undermined  by  malnutrition  or  some 
constitutional  disease,  such  as  tuberculosis  or  syphilis.  Influenza 
attacks  strong  healthy  children,  as  well  as  weaklings,  and  the  mortality 
among  children  varies  to  a  certain  extent  in  different  epidemics. 

Treatment. — All  cases  should  be  isolated  because  of  the  contagious- 
ness of  the  disease,  and  after  recovery  the  sick-room  should  be  fumi- 
gated. Children  should  immediately  be  put  to  bed,  and  remain  there 
until  after  the  attack  has  subsided,  when  they  may  be  allowed  to 
play  about  in  one  or  two  rooms  from  which  the  other  members  of  the 
family  are  excluded.  The  bowels  should  be  freely  opened  by  the  use 
of  castor  oil,  1  dram  to  I  ounce,  or  some  other  purgative,  such  as  mag- 
nesium citrate,  2  to  6  ounces,  or  magnesium  sulphate,  1  to  2  drams. 
If,  in  infants,  there  is  diarrhea,  they  should  also  be  given  an  enema, 
and  no  milk  should  be  allowed  until  improvement  takes  place.  In 
its  place  albumen-water,  oatmeal  gruel,  rice-  or  barley-water,  or  beef 
juice  may  be  given  at  frequent  intervals,  the  amount  depending  upon 
the  age  of  the  child  and  severity  of  the  symptoms. 

Fever  should  be  combated  by  sponging  or  by  a  tepid  bath  with  the 
water  at  about  98°  F.  Following  the  bath  the  child  should  be  well 
rubbed.  An  ice-bag  may  be  kept  upon  the  head,  and  in  some  cases 
it  affords  relief  if  applied  to  the  chest,  being  moved  about  every 
half-hour. 

The  nervous  symptoms  accompanying  the  disease  should  be  con- 
trolled by  the  use  of  phenacetin,  2|  grains  night  and  morning,  or 
Dover's  powder,  |  to  1  grain,  or  codein  sulphate,  ^-j  to  ^o"  of  a  grain. 
Should  there  be  cardiac  weakness  nothing  is  quite  so  efficient  as 
alcoholic  stimulation,  and  10  to  30  drops  of  whisky  or  brandy  may  be 
given  every  three  hours,  if  necessary.  Other  cardiac  stimulants 
which  may  be  used  are  strychnine  and  digitalis,  ^o"  to  ^o^o"  of  a  grain  of 
strychnine  sulphate,  and  1  to  3  drops  of  tincture  of  digitalis  (or  y  g-  to 
I  grain  of  strophanthus)  may  be  administered  every  three  hours. 

In  older  children  the  use  of  quinine  sulphate,  ^  tol  grain,  is  of  decided 
benefit,  particularly  if  combined  with  either  phenacetin,  1  grain,  or 
Dover's  powder,  1  grain,  and  given  every  six  hours.  Its  use  in  infants 
is  not  so  highly  recommended  because  of  its  tendency  to  upset  the 
stomach. 

The  cough  which  accompanies  influenza  may  be  relieved  by  the  use 
of  codein  sulphate,  4V  to  2V  of  a  grain,  or  heroin  hydrochloride,  5-V  to 
^V  of  a  grain  three  times  a  day,  the  dose  of  these  drugs  depending 
upon  the  age  of  the  child.  Much  can  be  done  to  prevent  pneumonia 
and  otitis,  as  well  as  other  complications,  by  spraying  the  nasopharynx 
two  or  three  times  daily  with  a  saturated  boric  acid  solution  or  normal 
saline.  When  the  cough  lasts  for  some  time  after  an  acute  attack, 
it  is  best  combated  by  the  use  of  cod-liver  oil,  to  which  is  added  5  drops 


SMALLPOX  707 

of  creosote  to  the  ounce,  and  ^  to  1  dram  of  this  may  be  given  two  or 
three  times  daily. 

The  diet  should  be  carefully  regulated.  All  children  who  have  any 
tendency  to  pulmonary  disease,  particularly  tuberculosis,  should  be 
carefully  guarded,  and  they  should,  if  possible,  if  the  attack  occurs 
during  the  winter  months,  be  removed  to  a  mild  and  equable  climate. 
Such  whiter  resorts  as  Brown's  Mills  in  the  Pines,  or  Old  Point  Comfort, 
provide  an  ideal  climate  for  convalescence  in  these  cases. 

In  influenzal  meningitis,  the  use  of  the  specific  serum  which  has  now 
been  placed  on  the  market  is  strongly  urged,  since  it  bears  the  same 
relation  to  the  disease,  and  is  of  the  same  significance,  as  is  Flexner's 
serum  in  cerebrospinal  meningitis. 

SMALLPOX  (VARIOLA). 

Smallpox  is  an  acute  infectious  disease,  characterized  by  an  erup- 
tion of  the  skin  which  passes  through  successive  stages  of  papule, 
vesicle,  pustule,  and  crust. 

History. — It  is  believed  to  have  existed  in  China  at  least  a  thousand 
years  before  the  Christian  era.  It  was  imported  into  this  country 
in  the  latter  part  of  the  sixteenth  century  by  the  Spanish.  In  910, 
Rhazes  wrote  the  first  description  of  smallpox,  and  it  was  first  dis- 
tinguished from  measles  by  an  Arabian  physician,  Avicenna  by  name. 

Etiology. — Natural  immunity  to  the  disease  is  rare,  and  those 
exposed,  unless  protected  by  vaccination,  are  almost  certain  to  be 
attacked.  In  the  majority  of  instances,  one  attack  protects  against  a 
second,  though  second  and  even  third  attacks  have  been  reported. 
It  is  exceptionally  fatal  in  children  under  ten  years  of  age,  but  may 
affect  persons  of  all  ages.  A  pregnant  mother  may  contract  the  disease, 
and  the  fetus  in  idero  be  attacked  at  the  same  time.  Males  and 
females  are  equally  affected.  Negroes  are  particularly  susceptible, 
and  the  mortality  among  them  is  greater  than  in  the  white  race, 
the  ratio  being  almost  two  to  one.  In  temperate  climates  it  is  looked 
upon  as  a  cool  weather  disease,  and  in  tropical  countries  is  regarded 
as  a  hot  weather  malady  which  ameliorates  as  cooler  weather 
approaches.  Once  implanted  in  a  community,  the  disease  rapidly 
spreads,  but  the  virulence  of  epidemics  in  different  localities  varies 
greatly.  In  the  United  States  the  disease  is  steadily  on  the  decrease, 
as  it  is  in  all  other  countries  where  vaccination  is  practised. 

Contagion. — There  is  no  doubt  that  smallpox  is  the  result  of  infection 
by  a  specific  organism,  and  that  this  organism  is  present  in  the  blood 
has  been  proven  by  inoculating  a  monkey  with  blood  from  a  person 
suffering  with  the  disease.  It  is  also  present  in  the  pustules,  the  pus 
from  these,  when  inoculated  into  a  human  being,  producing  smallpox. 
Unquestionably  also  it  is  present  in  the  exlialations,  and  the  infection 
may  be  carried  by  a  second  person  or  by  the  atmosphere.  Clothing 
and  other  articles  which  have  come  in  contact  with  the  patient  may 
also  be  a  means  of  conveying  infection. 


708  THE  SPECIFIC  INFECTIOUS  DISEASES 

The  period  in  which  smallpox  is  most  contagious  is  during  the  stage 
of  suppuration  and  early  dessication.  A  case  has  been  recorded  by 
Austin  Flint  in  which  the  contagion  was  spread  by  a  cadaver.  Domestic 
animals  and  insects  may  also  transmit  it.  In  most  cases  the  disease 
is  contracted  by  direct  contact,  and  such  contact  need  not  necessarily 
be  for  any  great  length  of  time,  inasmuch  as  the  slightest  exposure  to 
smallpox  is  often  followed  by  an  attack.  The  severity  of  the  illness 
in  one  person  does  not  necessarily  imply  that  other  individuals,  who 
contract  the  disease  from  having  come  into  contact  with  him,  will 
have  a  severe  attack,  for  the  disease  when  acquired  from  one  suffering 
with  it  in  virulent  form,  such  as  hemorrhagic  smallpox,  is  often 
exceedingly  mild,  and  the  reverse  may  also  be  true. 

The  nature  of  the  contagion  is  not  definitely  known,  although 
Councilman  has  described  a  protozoon  which  gains  entrance  into  the 
nuclei  of  the  epithelial  cells,  and  causes  the  formation  of  minute 
vacuoles  about  a  central  vacuole.  The  life-history  of  the  organism 
has  been  further  studied,  and  its  relation  to  the  skin  lesions  of  smallpox 
give  the  impression  that  it  is  the  actual  cause  of  the  disease. 

Pathology. — In  some  cases  the  mucous  membrane  of  the  mouth 
and  pharynx  is  the  seat  of  pustules,  and,  indeed,  there  have  been 
instances  where  the  rash  has  extended  down  the  esophagus  and  into 
the  stomach.  It  may  also  involve  the  trachea  and  bronchi;  and, 
although  no  true  pocks  are  found  in  the  bronchi,  bronchitis,  broncho- 
pneumonia, lobar  pneumonia,  and  pleurisy  are  occasionally  associated 
with  it.  The  spleen  becomes  greatly  enlarged,  and  the  kidneys  fre- 
quently are  the  seat  of  cloudy  sw^elling;  often  minute  areas  of  necrosis 
may  be  seen.  The  heart  may  be  the  seat  of  myocardial  changes, 
chiefly  of  a  parenchymatous  or  fatty  nature.  In  the  hemorrhagic 
form  of  the  disease  the  serous  and  mucous  surfaces  and  parenchyma 
of  various  organs  become  the  seat  of  extravasations.  At  times  there 
is  hemorrhage  in  the  bone-marrow. 

Histologically  the  pustule  begins  in  the  rete  mucosa,  and  consists 
of  a  central  area  of  coagulation  necrosis,  surrounded  by  an  infiltration 
of  leukocytes  together  with  serum  and  fibrin.  In  the  more  severe 
forms  of  pustule,  infiltration  extends  into  the  papillae  of  the  skin, 
causing  their  destruction,  which  terminates  in  the  formation  of  a 
pit. 

Symptoms. — The  types  of  smallpox  described  are: 

1.  Variola  vera. 

(a)  Discrete. 

(b)  Confluent. 

2.  Variola  hemorrhagica. 

(a)  Purpura  variolosa. 

(b)  Variola  hemorrhagica  pustulosa. 

3.  Varioloid — smallpox  modified  by  vaccination. 

The  period  of  incubation  is  usually  from  seven  to  fourteen  days. 
The  onset  is  sudden,  accompanied  by  severe  headache  and  backache, 
which  in  adults  are  sometimes  preceded  by  a  chill.    In  children  the 


SMALLPOX  709 

only  initial  symptom  may  be  a  convulsion.  Fever  follows^  often  reach- 
ing 103°  to  104°  F.  during  the  first  twentj^-four  hours.  The  pulse 
becomes  rapid  and  bounding,  and  at  this  stage  there  is  frequently 
delirium.  Constipation  and  persistent  vomiting  may  become  prom- 
inent. Usually  a  violent  frontal  headache,  vertigo,  and  severe  pains 
in  the  lumbar  region  are  complained  of. 

The  initial  rash  makes  its  appearance  on  the  second  day,  either  as  a 
diffuse  scarlatinous  or  a  measly  form,  and  covers  a  certain  portion 
of  the  body  surface,  though  it  is  usually  confined  to  the  abdomen, 
the  inner  surface  of  the  thighs,  and  the  axillae.  On  or  about  the  fourth 
day  small  red  spots  make  their  appearance,  first  on  the  forehead 
and  wrists,  followed  by  rapid  extension  over  the  face,  abdomen,  and 
extremities.  Within  another  twenty-four  hours  these  papules  acquire 
a  characteristic  shot-like  hardness,  and  at  this  time  there  is  an  amelio- 
ration of  symptoms — namely,  a  drop  in  temperature  and  general 
relief  from  the  violent  headache  and  backache.  On  the  sixth  day 
the  papules  become  vesicular  and  depressed,  thus  forming  what  is 
known  as  the  umbilication,  which  is  extremely  characteristic  of  the 
smallpox  eruption.  The  fluid  in  the  vesicle  increases  in  turbidity 
until  about  the  eighth  day,  when  it  becomes  intensely  yellow  and  the 
umbilication  disappears,  thus  forming  a  pustule. 

At  this  time  there  is  a  return  of  fever  and,  because  of  the  tension 
about  the  eruption,  some  degree  of  pain  in  these  parts.  On  or  about 
the  eleventh  day  the  pustules  begin  to  dry,  and  this  continues  until 
the  fourteenth  day,  when  crusts  are  formed  which  fall  off,  leaving 
either  a  slight  discoloration,  as  in  the  milder  types,  or  an  ulcer,  or  a  pit, 
according  to  the  degree  of  cicatrization.  By  this  time  the  secondary 
fever  has  about  disappeared. 

Many  variations  of  the  eruption  may  be  noted,  the  preceding 
description  being  that  of  the  usual  simple  or  discrete  variety.  When 
the  pustules  are  in  close  proximity,  they  may  unite,  thus  producing 
the  confluent  variety,  and  when  accompanied  by  bloody  infiltration 
the  term  hemorrhagic  smallpox  is  used. 

In  the  confluent  type  of  the  disease,  the  eruption  usually  makes  its 
appearance  earlier  than  in  the  discrete  form,  that  is,  on  the  third  day. 
The  symptoms  are  usually  aggravated,  and  there  is  no  abatement  of 
the  fever  when  the  rash  appears,  as  is  the  case  in  the  discrete  form. 
In  the  confluent  form  of  the  disease  we  may  sometimes  see  enormous 
pus  vesicles,  some  part  of  which  may  be  dry  as  the  result  of  early 
rupture  here  and  there.  In  the  more  severe  cases  of  this  type  extreme 
exhaustion  makes  its  appearance  on  or  about  the  tenth  day,  and 
frequently  brings  about  a  fatal  termination. 

The  hemorrhagic  form  of  the  disease  is  even  more  severe  than  the 
confluent.  Two  types  are  described.  The  first  is  purpura  variolosa, 
in  which  hemorrhage  makes  its  appearance  early  in  the  form  of  a 
hemorrhagic  rash,  together  with  hemorrhage  from  the  mucous  surface 
which  often  occurs  as  early  as  the  second  or  third  day.  Death  usually 
soon  foflows.     In  the  second  form,  known  as  variola  hemorrhagica 


710  THE  SPECIFIC  INFECTIOUS  DISEASES 

pustulosa,  the  disease  follows  the  usual  course  until  the  vesicular  or 
pustular  stage  is  reached,  when  hemorrhagic  symptoms  manifest 
themselves  by  the  appearance  of  blood  in  the  pocks. 

VARIOLOID. 

This  variety,  which  is  variola  modified  either  by  vaccination  or  a 
previous  attack  of  smallpox,  is  characterized  by  the  extreme  mildness 
of  its  symptoms,  and  by  early  convalescence.  The  fever  is  less,  and 
the  eruption  exceedingly  light,  sometimes  failing  to  show  its  successive 
stages.  Usually  the  interval  between  vaccination  and  the  attack  is 
the  factor  which  determines  the  severity;  that  is,  the  longer  the 
interval  between  the  two,  the  more  severe  the  disease  is  apt  to  be. 

Abortive  Types. — Various  modifications  of  smallpox  may  be  noted  in 
different  epidemics.  In  unvaccinated  children  there  may  sometimes 
be  but  a  few  pustules,  and  the  disease  may  terminate  uneventfully 
in  a  few  days;  again  the  vesicle  may,  instead  of  becoming  filled  with 
pus,  dry  and  disappear,  giving  rise  to  the  so-called  ivart-pox.  Another 
form,  known  as  variolce  sine  variolis  may  be  seen  in  which  all  the 
symptoms  of  the  disease  are  present  except  the  eruption;  such  cases 
are  not  numerous. 

Diagnosis. — Vomiting  preceded  by  a  chill  and  accompanied  by 
severe  headache  and  backache  should  arouse  suspicion,  particularly 
so  if  there  is  a  history  of  exposure  to  smallpox.  When  the  eruption  is 
typical,  the  diagnosis  is  easily  made,  for  in  no  other  disease  do  we 
find  such  a  profuse  pustular  eruption  as  in  smallpox;  but  in  mild  cases 
and  those  modified  by  vaccination  the  diagnosis  is  sometimes  a  matter 
of  great  difficulty.  Much  importance  should  be  attached  to  a  history 
of  exposure,  to  the  presence  or  absence  of  a  recent  and  good  vaccination 
mark,  and  to  the  visible  signs  of  a  preceding  attack  of  smallpox.  A 
positive  diagnosis  is  scarcely  possible  before  the  appearance  of  the  rash. 
The  primary  rash  might  be  confused  with  that  of  scarlet  fever  or 
measles,  but  other  symptoms  of  the  two  latter  diseases  ought  to  aid 
in  the  differentiation. 

The  constitutional  symptoms  of  smallpox  are,  however,  more  severe 
than  those  of  measles,  and  in  variola  the  fever  declines  before  the 
appearance  of  the  eruption,  while  in  measles  the  temperature  is  usually 
at  its  height  at  the  time  of  the  eruption.  In  smallpox  there  is  no 
prodromal  catarrhal  inflammation  of  the  upper  respiratory  tract,  and 
the  eyes  are  not  inflamed.    Koplik's  spots  are  not  seen  in  smallpox. 

Scarlet  fever  may  be  differentiated  from  smallpox  by  the  prodromal 
rash,  sore  throat,  and  the  absence  of  severe  lumbar  pains.  The  symp- 
toms of  the  two  diseases  are  also  essential  points  in  the  differentiation. 
In  the  malignant  hemorrhagic  type  of  the  disease,  death  may  occur 
prior  to  the  appearance  of  the  characteristic  eruption,  and  in  such  cases 
it  is  extremely  difficult  to  distinguish  it  from  hemorrhagic  scarlet  fever 
and  hemorrhagic  measles. 

The  disease  with  which  smallpox  is  most  frequently  confounded 


VARIOLOID  711 

is  varicella,  and  this  occurs  most  often  when  the  disease  assumes  a 
mild  form.  The  most  valuable  points  in  the  differentiation  of  the  two 
diseases  are  as  follows: 

In  varicella  the  prodromal  symptoms  are  not  as  intense  as  in  small- 
pox. It  is  more  apt  to  occur  in  children  than  in  adults.  The  rash  is 
most  abundant  about  the  trunk,  and  it  appears  in  crops.  The  papules 
do  not  have  a  "shot-like"  feeling,  the  vesicles  are  superficial,  and 
ruptured  by  the  slightest  pressure.  There  is  little  or  no  infiltration 
about  the  pocks.  Finally,  the  presence  or  absence  of  a  good  vac- 
cination mark  is  a  determining  factor  in  making  the  differential 
diagnosis. 

Pustular  syphilid  may  be  confounded  with  the  disease,  particularly 
if  accompanied  by  fever;  but  the  absence  of,  or  merely  a  slight,  rash 
on  the  face  in  syphilis,  together  with  the  history  of  a  primary  lesion 
in  adults,  or  a  Wassermann  reaction,  should  be  our  guide. 

Confusion  may  also  arise  in  differentiating  the  hemorrhagic  variety 
of  the  disease  from  cerebrospinal  fever.  The  eruptions  of  acne,  eczema, 
syphilis  (pustular),  and  vaccinia  have,  in  a  few  instances,  been  con- 
fused with  the  eruption  of  smallpox. 

Complications. — Among  these  are  laryngitis  followed  by  fatal  edema 
of  the  glottis,  necrosis  of  the  cartilages,  and  bronchopneumonia 
induced  by  the  aspiration  of  particles  into  the  lower  air  passages 
owing  to  the  diminished  sensibility  of  the  larynx.  Almost  all  of  the 
fatal  cases  show  evidences  of  bronchopneumonia. 

Cardiac  complications  are  also  seen  in  the  form  of  myocarditis 
and  pericarditis,  more  rarely  endocarditis.  During  the  height  of  the 
primary  fever  a  systolic  murmur  may  sometimes  be  heard  at  the  apex. 
Of  complications  in  the  digestive  system,  diarrhea  is  in  all  probability 
the  most  frequent,  especially  in  children.  Nephritis  is  rare,  although 
albuminuria  is  frequent.  Occasionally  there  may  be  inflammation 
of  the  ovaries  and  testes.  The  skin  may  be  the  seat  of  boils,  acne,  and 
ecthyma,  and  occasionally  of  small  areas  of  gangrene.  Violent  con- 
junctivitis may  result  from  neglect  of  the  eyes,  and  there  may  be 
a  dift'use  keratitis.  Otitis  media  may  result  from  extension  of  the 
disease  by  way  of  the  Eustachian  tubes. 

Complications  of  the  nervous  system  may  be  serious.  The  delirium 
so  common  during  the  early  stages  of  the  disease  may  increase  in 
intensity,  and  be  prolonged  indefinitely,  until  it  results  in  fatal  coma. 
Insanity  occasionally  develops  during  convalescence. 

Arthritis  may  make  its  appearance  during  the  stage  of  desquama- 
tion, and  may  terminate  in  suppuration. 

Prognosis. — Age,  race,  and  the  type  of  the  epidemic  are  the  chief 
determining  factors  in  the  death-rate.  The  mortality  is  extremely 
high  in  the  young.  In  the  epidemic  which  occurred  in  Montreal, 
in  1885,  86  per  cent,  of  the  total  number  of  deaths  occurred  in  children 
under  ten  years  of  age.  The  average  mortality  is  from  25  to  35  per 
cent.  The  mortality  of  varioloid  is  much  lower,  ranging  from  10  per 
cent,  in  infancy  to  5  per  cent,  in  older  children.    Complications,  such 


712  THE  SPECIFIC  INFECTIOUS  DISEASES 

as  pneumonia  and  laryngitis,  are  always  serious,  and  recovery  from 
hemorrhagic  smallpox  is  rare. 

Treatment. — The  child  should  be  isolated,  and,  if  possible,  promptly 
removed  to  a  smallpox  hospital.  If  seen  early  in  the  attack  it  should 
be  vaccinated  at  once.  If  the  child  remains  at  home,  it  should  pre- 
ferably be  isolated  on  an  upper  floor,  and  all  communication  with  the 
rest  of  the  household  cut  off.  Sheets  saturated  or  dampened  with  a 
solution  of  carbolic  acid  should  be  hung  at  the  doors.  All  unnecessary 
furniture  and  all  carpets  and  hangings  should  be  removed  from  the 
room.  There  should  be  separate  eating  utensils.  The  nurse  in  attend- 
ance should  wear  a  gown  that  completely  covers  her  ordinary  dress, 
and  should  not  come  in  contact  with  any  one  save  the  sick  child. 

The  treatment  is  chiefly  symptomatic.  The  violent  pain  in  the 
back  of  the  head  is  controlled  chiefly  by  the  use  of  sedatives,  such  as 
morphine  sulphate,  gr.  ^g-  to  y^  every  four  hours,  in  the  more  severe 
cases,  and  phenacetin,  1  to  3  grains  every  four  hours,  or  antipyrin,  1 
grain  every  four  hours,  in  the  milder  cases. 

The  food  should  be  liquid.  When  there  is  prostration  stimulation 
should  be  resorted  to,  and  for  this  purpose  10  to  30  drops  of  brandy, 
or  "strychnine  sulphate,  gr.  ^j^q  to  y^,  may  be  administered  every 
three  hoiu-s. 

If  vomiting  is  persistent,  10  to  20  grains  of  bismuth  subnitrate, 
I  of  a  grain  of  cerium  oxalate,  ^  to  1  dram  of  iced  champagne,  or  simply 
cracked  ice,  may  be  given  to  check  it. 

Quinine  sulphate,  i  to  |  grain,  should  be  gWen  every  four  hours 
when  the  fever  runs  high,  and  the  temperature  may  also  be  reduced 
by  sponging.  In  instances  also  where  delirium  is  marked,  baths 
should  be  resorted  to.  These  should  not  be  given  cool  at  first;  but, 
if  a  bath  with  friction  at  95°  F.  does  not  bring  down  the  fever,  the 
temperature  of  the  water  may  be  gradually  lowered  from  95°  to  80°  F. 
Plenty  of  cold  water  should  be  given  the  child  to  drink,  as  in  fevers  of 
other  t^'pes. 

The  treatment  of  the  eruption  is  important,  in  order  to  prevent,  if 
possible,  the  disfigurement  which  so  frequently  follows  severe  attacks 
of  smallpox.  Various  methods  have  been  tried,  but  none  with  satis- 
factory results.  The  application  of  a  cold  weak  solution  of  carbolic 
acid  or  bicliloride  of  mercury  upon  gauze  is  in  all  probability  one  of  the 
most  effective  methods  in  use  today.  During  the  first  seven  or  eight 
days  of  the  eruption,  tincture  of  iodine,  either  full  or  half-strength, 
may  be  painted  once  or  twice  a  day  over  the  face  or  any  other  portion 
of  the  body  where  the  eruption  is  profuse.  ]\Iany  physicians  claim 
most  excellent  results  from  this  treatment.  In  order  to  prevent  dis- 
semination of  the  epidermis  during  the  stage  of  crust  formation,  it  is 
expedient  to  apply  an  ointment,  such  as  vaseline  or  cold  cream,  freely 
over  the  skin  surface. 

Treatment  of  the  complications  requires  consideration.  In  children, 
if  diarrhea  is  severe,  opium  in  the  form  of  paregoric  should  be  admin- 
istered in  10-  to  20-drop  doses  every  six  hours.    Tracheotomy  may  be 


VACCINIA  713 

necessary  if  the  symptoms  point  to  obstruetion  of  the  larynx  by  edema. 
Great  care  should  be  exercised  to  prevent  the  occurrence  of  bed-sores. 
The  eyes  should  be  kept  absolutely  clean  with  a  solution  of  boracic 
acid,  which  will  lessen  the  probability  of  keratitis.  The  nose,  mouth, 
and  throat  should  also  be  cleansed  frequently  to  prevent,  if  possible, 
the  formation  of  hard  crusts.  In  addition,  the  mouth  and  nasopharynx 
should  be. sprayed  with  a  1  to  5000  solution  of  potassium  permanganate, 
or  a  1  to  5  solution  of  hydrogen  peroxide,  once  or  twice  a  day. 

During  the  stage  of  convalescence  great  care  should  be  exercised 
as  to  cleanliness  and  changing  the  position  of  the  child,  to  prevent  the 
formation  of  bed-sores  or  pulmonary  complications.  There  should' be 
daily  baths  followed  by  inunctions  with  olive  oil.  This  should  be  con- 
tinued until  the  whole  skin  surface  is  smooth,  and  all  evidences  of 
scab  formation  have  disappeared,  since  these  scabs  are  potent  factors 
in  the  further  dissemination  of  the  disease. 

VACCINIA  (COW-POX). 

Vaccinia  is  an  eruptive  disease  of  cattle,  communicable  to  man 
only  by  inoculation  (vaccination),  in  which  event  it  produces  one  or 
more  lesions,  according  to  the  number  of  points  of  inoculation.  General 
vaccinia,  in  which  the  lesions  are  scattered  irregularly  all  over  the 
surface  of  the  body,  occurs  in  about  2  per  cent,  of  all  children  who  are 
vaccinated.  The  eruption  is  frequently  the  result  of  auto-inoculation 
from  the  original  site  of  vaccination,  and  may  be  erythematous, 
urticarial,  scarlatiniform,  vesicular,  bullous,  pustular,  or  pemphigoid, 
although  the  most  common  type  is  the  urticarial. 

It  usually  appears  from  the  fourth  to  the  tenth  day  after  vaccination, 
but  in  exceptional  cases  may  occur  weeks  later.  As  a  rule  the  eruption 
appears  in  successive  crops,  and  the  lesions  are  first  papular,  then 
vesicular,  and  finally  become  pustules,  thus  resembling  the  original 
sore.  The  eruption  may  be  seen  in  all  of  its  different  stages  of  develop- 
ment upon  the  same  individual. 

There  may  be  a  variable  degree  of  fever,  this  depending  upon  the 
number  and  extent  of  the  lesions.  In  the  scalatiniform  variety  there 
is  usually  great  discomfort  and  a  feeling  of  malaise,  as  well  as  moderate 
fever. 

Auto-inoculation  is  common  in  children  who  have  affections  of  the 
skin  which  cause  a  break  in  its  continuity.  These  lesions  become 
inoculated  with  virus  from  the  original  sore,  and  a  profuse  eruption  of 
vaccinia  may  appear.  The  lesions  may  be  discrete,  but  often  become 
confluent,  and  bear  some  resemblance  to  the  original  vaccination  mark. 

Vaccinal  ophthalmia  may  also  be  caused  by  transmission  of  the 
virus  to  the  conjunctiva  by  means  of  the  child's  fingers  or  the  indis- 
criminate use  of  towels,  wash  rags,  and  sponges.  The  crusts  dry  and 
fall  off  at  the  end  of  the  third  week,  and,  as  a  rule,  the  lesions  of  general 
vaccinia  entirely  disappear  after  this  time,  and  there  are  no  more  new 
crops.     Such  inoculation  confers  protection  against  smallpox. 


714  THE  SPECIFIC  INFECTIOUS  DISEASES 

History. — ^While  Edward  Jenner  was  a  medical  student  at  Sodbury, 
he  became  acquainted  with  the  fact  that  cowpox  protected  against 
smallpox.  This  he  learned  from  a  young  country  girl  who^  on  hearing 
smallpox  mentioned,  exclaimed  "  I  cannot  take  that  disease,  for  I  have 
had  cow-pox."  Jenner  mentioned  the  fact  to  Hunter,  who  advised 
him  to  be  inoculated,  and  thus  prove  the  accuracy  of  the  country 
girl's  statement. 

All  this  occurred  in  1780,  but  it  was  not  until  1796  that  Jenner 
inoculated  a  boy,  named  James  Phipps,  eight  years  of  age,  with  virus 
from  the  hand  of  a  dairy  maid,  Sarah  Nelmes,  who  at  the  time  was 
sufi^ering  with  cow-pox.  As  early  as  1774,  Benjamin  Jesty,  a  Yetminster 
farmer,  vaccinated  his  wife  and  children  with  matter  taken  from  cows 
that  were  suffering  with  cow-pox.  Subsequently  his  children  were 
inoculated  with  matter  from  the  lesions  of  smallpox,  and  did  not  take 
the  disease.  Nevertheless,  the  credit  must  be  given  to  Jenner  for 
establishing  the  fact  that  cow-pox  did  protect  against  smallpox,  and 
this  truth  was  established  only  after  much  study  and  experimentation. 
It  was  not  until  the  year  1800  that  cow-pox  was  introduced  into  the 
United  States  by  Benjamin  Waterhouse,  Professor  of  Phj^sics  at 
Harvard,  who  at  that  time  successfully  vaccinated  seven  of  his  children. 
Two  years  later  nineteen  boys  were  inoculated,  twelve  of  the  number 
being  subsequently  inoculated  with  smallpox,  and  all  showed  immunity 
to  the  disease.  Two  unvaccinated  boys  were  inoculated  with  the 
same  smallpox  virus,  and  both  contracted  the  disease. 

Jenner  died  on  January  6,  1.823,  and  twelve  days  prior  to  his  death 
he  wrote  as  follows:  "My  opinion  of  vaccination  is  precisely  as  it 
was  when  I  first  promulgated  the  discovery.  It  is  not  in  the  least 
strengthened  by  any  event  that  has  happened,  for  it  could  gain  no 
strength.  It  is  not  in  the  least  weakened,  for,  if  the  failures  you  speak 
of  had  not  happened,  the  truth  of  my  assertions  respecting  those 
coincidences  which  have  occasioned  them,  would  not  have  been  made 
out." 

Vaccine  Virus. — Two  types  of  virus  exist,  the  humanized  and  the 
bovine  type. 

Humanized  Virus. — Humanized  virus  is  seldom  used  at  present 
because  of  the  possibility  of  the  subject  having  syphilis,  hereditary  or 
acquired,  or  some  other  constitutional  disease.  When  used  it  should 
be  taken  from  a  vaccine  pock  of  the  fifth  to  the  eighth  day,  and  such 
a  vesicle  should  be  primary  and  contain  clear  fluid.  Should  there 
exist  any  inflammatory  condition  other  than  that  normally  present, 
another  individual  should  be  sought.  Usually  the  virus  is  obtained 
from  young  subjects  because  of  the  slighter  possibility  of  their  having 
transmissible  diseases. 

To  obtain  the  lymph  a  vesicle  is  punctured  and  a  capillary  tube 
inserted  in  the  puncture.  The  tube  is  then  sealed,  and  kept  in  a  cool 
place  until  needed  for  use,  at  which  time  the  ends  of  the  tube  are 
broken,  and  the  lymph  is  expelled  by  means  of  a  small  rubber  bulb. 


VACCINIA  715 

Bovine  Virus. — Two  types  of  this  virus  are  employed:  namely, 
lymph  and  vesicle  pulp.  The  former  is  merely  the  clear  lymph  from 
a  vaccine  vesicle,  while  the  latter  is  a  combination  of  not  only  the 
lymph,  but  also  the  epithelial  lining  of  the  pock.  This  has  been 
found  to  be  more  active  than  lymph  alone.  The  lymph  may  be  used 
in  a  dry  form  upon  points  of  ivory  or  celluloid,  which  are  known  as 
dry  points,  or  in  the  form  of  a  glycerinated  emulsion  which  is  marketed 
in  sealed  tubes.    The  latter  form  is  the  one  most  frequently  used. 

Vaccination. — Nowadays  the  custom  of  vaccinating  children  between 
the  ages  of  four  and  six  months  has  become  popular.  Should  there  be 
an  epidemic  of  smallpox,  or  a  history  of  contact  with  smallpox,  no 
matter  what  the  age  of  the  child  may  be  or  whatever  else  the  child 
may  be  suffering  from  at  the  time,  it  should  be  immediately  vaccinated. 
If  there  is  no  smallpox  about,  the  physician  ought  to  decide  when  the 
child  should  be  vaccinated,  and  this  should  be  when  it  is  in  good 
physical  condition. 

Technic  of  Vaccination. — The  part  to  be  vaccinated  (preferably  the 
left  arm  in  boys  and  the  calf  of  the  leg  in  girls)  should  be  thoroughly 
disinfected  in  the  following  manner:  The  part  should  be  first  washed 
with  tincture  of  green  soap  and  water,  and  this  followed  by  an  applica- 
tion of  alcohol,  then  dried,  cleansed  with  sterile  water,  and  again 
dried  with  either  a  clean  piece  of  gauze  or  a  clean  towel.  The  abrasion 
necessary  for  inoculation  of  the  virus  should  be  made  either  with  a 
lancet  or  a  needle,  either  of  which  must  have  been  previously  rendered 
sterile  by  immersion  in  alcohol.  The  needle  is  preferable  in  view  of 
the  fact  that  a  new  one  may  be  used  at  each  vaccination.  Such  an 
abrasion,  if  on  the  arm,  is  usually  made  at  the  insertion  of  the  deltoid 
muscle,  with  cross-scarifications  about  one-third  of  an  inch  in  length 
and  extremely  superficial  in  order  to  draw  only  lymph.  If  blood  is 
drawn  it  has  a  tendency  to  prevent  absorption,  and  if  the  scarifica- 
tions are  deep  there  is  a  possibility  of  severe  inflammation  subsequently. 
The  virus  should  then  be  expressed  upon  the  abraded  area,  and  care- 
fully rubbed  in,  which  often  precludes  the  possibility  of  failure.  The 
lymph  should  then  be  allowed  to  dry  by  exposure  to  the  air,  after  which 
it  is  covered  with  a  sterile  piece  of  gauze. 

Shields  should  not  be  applied,  as  they  have  a  tendency  to  produce 
congestion  by  pressure.  To  protect  the  vaccinated  area  it  is  advisable 
to  keep  it  covered,  either  with  sterile  gauze  or  by  sewing  a  small  piece 
of  clean  gauze  to  the  sleeve  of  the  undershirt  or  to  the  inside  of  the 
stocking.  Should  the  vesicle  be  injured,  great  care  must  be  exercised 
to  prevent  its  infection  by  other  organisms. 

Vaccination  may  also  be  performed  hypodermically  by  the  use  of  a 
hypodermic  needle.  In  this  method  several  punctures  are  made  quite 
superficially,  and  the  lymph  is  injected. 

Stages  and  Symptoms  of  Vaccinia. — Practically  no  symptoms  are 
manifest  during  the  first  and  second  days  after  vaccination.  On  about 
the  fourth  day,  a  redness  appears  about  the  site  of  inoculation  which 
increases,  then  a  papule  forms,  more  flat  than  elevated,  which  becomes 


716  THE  SPECIFIC  INFECTIOUS  DISEASES 

vesicular  on  the  fifth  day,  and  attains  its  maximum  size  by  the  eighth. 
The  vesicle  formed  is  depressed  in  the  centre,  elevated  at  the  margins, 
and  contains  a  clear,  thin,  transparent  fluid.  On  the  tenth  day  an 
extensive  areola  surrounds  the  vesicle,  the  contents  of  which  become 
purulent.  At  this  time  there  is  often  marked  induration,  swelling  and 
pain.  By  the  twelfth  day  the  areola  begins  to  lessen,  the  fluid  within 
the  vesicle  becomes  opaque,  and  shows  evidences  of  drying  up.  ^y  the 
fifteenth  day  desiccation  is  complete,  the  vesicle  dries  up,  and  a  hard 
crust  is  formed  which  usually  falls  oft'  at  the  end  of  the  third  or  the 
beginning  of  the  fourth  week,  leaving  a  pitted  red  scar  which  later 
becomes  pale. 

Following  vaccination  there  are  usually  constitutional  symptoms 
which  may  be  either  mild  or  marked,  according  to  the  degree  of 
inoculation.  Fever,  restlessness,  anorexia,  and  irritability  usually 
appear  on  the  third  or  fourth  day,  and  continue  until  the  tenth  or 
twelfth.  If  the  vaccination  is  on  the  arm,  the  axillary  glands  are 
frequently  affected,  and  become  enlarged  and  tender.  If  the  vaccina- 
tion be  on  the  leg,  the  inguinal  glands  may  show  the  same  disturbance. 

It  is  generally  conceded  that  people  should  be  revaccinated  every 
seventh  year  and  whenever  smallpox  is  prevalent. 

Not  infrequently  certain  irregularities  are  met  with  in  vaccination, 
such  as  complete  termination  in  a  week,  or  the  reverse — namely,  a 
very  slow  development  of  the  pocks.  There  may  be  ulceration  or 
infection  as  the  result  of  bruising  or  scratching,  or  a  number  of  vesicles 
may  appear  in  the  neighborhood  of  the  primary-  one,  or  secondary 
vesicles  may  form  in  other  parts  of  the  body.  Vaccination  may  even 
be  fatal  in  children  in  whom  severe  secondary  infection  takes  place. 

The  arm  may  become  quite  sore,  owing  to  a  marked  local  reaction. 
In  these  cases  moist  boric  acid  dressings  should  be  applied  continuously, 
or  a  1  per  cent,  picric  acid  solution  or  compound  tincture  of  benzoin 
may  be  painted  on  the  inflamed  areola  twice  daily.  The  various  other 
complications  of  vaccinia  are,  for  the  most  part,  surgical,  and  should 
be  treated  along  these  lines. 

Complications. — Ulceration,  sloughing,  and  cellulitis  may  result 
either  from  uncleanliness  or  from  injury  to  the  vesicle.  Various  skin 
disorders,  such  as  erythema,  urticaria,  erysipelas,  and  impetigo,  also 
glandular  abscesses,  either  axillary  or  inguinal,  may  follow  vaccination. 
Syphilis  may  be  contracted  b}^  the  use  of  humanized  virus  taken  from 
some  one  suft'ering  with  the  disease,  either  hereditary  or  acquired. 
Such  instances  are  indeed  rare,  and  are  of  little  or  no  likelihood  because 
of  the  almost  universal  use  of  animal  lymph. 

The  possibility  of  transmitting  bovine  tuberculosis  is  very  slight. 
Tetanus,  too,  is  fortunately  rare,  because  of  the  extreme  precautions 
observed  in  the  preparation  of  animal  lymph;  nowadays,  if  such  a 
complication  does  occur,  it  is  usually  due  to  infection  of  the  vaccine 
pock  following  an  injury. 

It  has  been  thought  that  vaccination  has  a  certain  beneficial  influence 
upon  the  course  of  some  constitutional  diseases,  particularly  syphilis 


TUBERCULOSIS  717 

and  tuberculosis.  But  the  reverse  is  true,  in  that  it  has  a  tendency  to 
light  up  or  bring  into  activity  a  latent  syphilitic  or  tuberdular  taint. 
The  general  opinion  prevails  that  if  vaccination  is  not  successful, 
provided  it  has  been  done  carefully,  it  indicates  a  certain  degree  of 
immunity  to  smallpox. 

Value  of  Vaccination. — In  communities  in  which  vaccination  is 
systematically  practised,  smallpox  is  seldom,  if  ever,  seen.  A  notable 
illustration  of  its  efficacy  is  the  fact  that  in  Berlin,  from  1795  to  1799, 
before  vaccination  was  made  compulsory,  65  per  cent,  of  the  deaths 
were  due  to  smallpox.  Following  the  introduction  of  vaccination,  the 
figures  for  the  ensuing  five  years  were  as  follows:  7.5  per  cent.;  6.4 
per  cent.;  0.7  per  cent.;  1.3  per  cent.;  and  0.2  per  cent.  The 
mortality  from  smallpox  in  persons  who  have 'previously  been  vac- 
cinated ranges  from  6  to  8  per  cent.;  in  the  unvaccinated  it  is  at 
least  35  per  cent.,  which  shows  the  protective  value  of  a  single 
vaccination. 

Contraindications. — In  the  absence  of  an  epidemic  of  smallpox,  it  is 
not  advisable  to  vaccinate  an  infant  until  after  it  is  three  months  old. 
In  older  children  the  contraindications  to  vaccination  are  general  or 
localized  skin  lesions,  either  syphilitic  or  tuberculous,  or  any  other 
severe  and  recurrent  skin  disease,  whether  acute  or  chronic.  Children 
who  have  just  recovered  from  an  exhausting  illness,  or  are  debilitated 
by  other  causes,  should  not  be  vaccinated  until  they  regain  their 
strength  and  normal  vitality. 

TUBERCULOSIS. 

Tuberculosis  is  an  mfectious  disease  caused  by  the  Bacillus  tuber- 
culosis, and  characterized  by  the  formation  of  tubercles  or  infiltra- 
tions which  become  caseous  or  sclerotic,  and  eventually  either 
ulcerate  or  calcify.    It  may  run  an  acute,  subacute,  or  chronic  course. 

Etiology. — The  tubercle  bacillus  was  discovered  in  1882,  by  Robert 
Koch.  It  is  a  rod-shaped  organism,  varying  in  length  from  1.5  to 
3.5  microns,  and  in  breadth  from  0.2  to  0.4  micron.  The  bacilli  are 
usually  slightly  curved,  and  often  beaded,  which  sometimes  causes 
them  to  be  confused  with  streptococci,  though  the  beads  of  tubercu- 
losis are  merely  vacuoles,  the  result  of  degeneration.  The  tubercle 
bacillus  is  immobile,  and  of  very  slow  growth  when  artificially  culti- 
vated. It  is  acid  fast,  that  is,  after  having  been  stained  by  means 
of  a  dye,  it  does  not  become  decolorized  when  treated  with  an  acid, 
but  there  are  other  organisms  which  possess  this  same  peculiarity; 
namely,  the  Bacillus  leprae  and  the  smegma  group.  The  tubercle 
bacillus  is  readily  killed  when  exposed  to  direct  smilight. 

The  culture  media  used  for  its  growth  are  blood  serum,  glycerin 
agar,  bouillon,  or  potato,  and  to  promote  their  growth  on  these  they 
should  be  kept  at  blood  heat  after  being  inoculated.  ■  The  colonies 
appear  as  grayish-white  masses  on  the  surface  of  the  culture  media. 
Occasionally  the  organisms  assume  a  branch-like  formation,  and  may 


718  THE  SPECIFIC  INFECTIOUS  DISEASES 

be  seen  as  minute  oval  or  round  bodies  which  take  a  deep  stain;  these 
are  known  as  Schron's  capsules. 

In  1901,  Koch  announced  that  human  and  bovine  bacilli  were 
different,  whereas  prior  to  this  time  he  had  considered  them  as  one 
and  the  same,  although  von  Behring  and  Ravenal  had  demonstrated 
by  experiments  that  the  bacillus  of  human  tuberculosis  is  capable 
of  producing  tuberculosis  in  cattle.  The  question  today  seems  to 
resolve  itself  into  a  probability  that  the  original  parentage  of  the 
organism  was  one  and  the  same,  and  that  differences  in  its  forms  and 
characteristics  were  produced  by  its  mode  of  life  and  its  host.  The 
disease,  so  far  as  is  known,  can  be  transmitted  from  man  to  cattle 
only  when  the  individual  is  excreting  organisms  of  the  bovine  type. 
On  the  other  hand,  it  is  possible  for  the  human  organism  to  become 
infected  by  the  bovine  bacillus. 

Parke  and  Krumweide,  in  a  study  of  132  children  between  the  ages 
of  5  and  16  years,  found  the  bovine  type  in  33  cases  which  were 
classified  as  follows: 

Tuberculous  cervical  adenitis 20 

Abdominal  tuberculosis 7 

Generalized  tuberculosis 3 

Bone  and  joint  tuberculosis 1 

Tuberculosis  of  tonsil 1 

Alimentary  tuberculosis 1 

In  another  study  of  220  children  under  five  years  of  age,  59  showed 
the  bovine  type  of  the  disease,  the  lesions  being  distributed  as  follows. 

Tuberculous  cervical  adenitis 20 

Abdominal  tuberculosis 13 

Generalized  tuberculosis 5 

Generalized  tuberculosis  (of  alimentary  origin) 10 

Generalized  tuberculosis  (including  meningitis) 2 

Generalized  tuberculosis  (including  meningitis  of  alimentary  origin)   .  8 

Tuberculous  meningitis 1 

Percentage  of  Bovine  Infections. 

Five  to  sixteen  Under  five 

years.     ,  years. 

Pulmonary  tuberculosis 0  0 

Adenitis  cervical  tuberculosis 37  57 

Abdominal  tuberculosis 50  68 

Generalized  tuberculosis 40  26 

Meningitis  tuberculosis 0  0 

Bone  and  joint  tuberculosis 3  0 

Parke  and  Krumweide  state  that  the  bovine  type  of  tubercle  bacillus 
is  a  menace  to  the  life  of  the  young  child,  and  causes  from  6  to  10 
per  cent,  of  the  total  fatalities  from  this  disease.  The  bovine  infection 
is  largely  limited  to  children,  but  is  fatal  only  in  infants  and  very 
young  children,  in  whom,  in  a  large  percentage  of  cases,  it  produces 
cervical  adenitis  and  the  rarer  forms  of  alimentary  tuberculosis. 
The  bovine  type,  as  a  rule,  causes  a  milder  form  of  tuberculosis  than 
the  human  type. 


TUBERCULOSIS  719 

Distribution. — The  bacilli  are  widely  distributed,  and  are  readily 
disseminated  by  an  individual  whose  secretions  contain  the  organisms. 
They  are  present  in  the  body  in  all  tubercular  lesions  save  in  the 
chronic  types  of  the  disease  which  involve  the  lymphatic  glands  and 
the  joints.  In  some  instances  they  are  present  in  the  blood,  and  in 
this  manner  gain  access  to  various  parts  of  the  body.  Outside  of 
the  body  they  are  distributed  chiefly  by  the  sputum  which  has  become 
dry  and  assumed  the  form  of  dust,  whereby  it  is  readily  disseminated 
from  place  to  place.  In  the  tuberculous  wards  of  hospitals,  organism 
have  been  grown  from  the  dust  collected,  and  when  inoculated  into 
animals  have  been  capable  of  producing  tuberculosis.  In  the  open 
air  they  are  rapidly  destroyed,  either  by  direct  sunlight  or  diffused 
daylight. 

The  bacillus  of  bovme  tuberculosis  is  found  in  the  secretions  and 
excretions  of  animals  suffermg  from  the  disease,  in  and  about  their 
stalls,  and  often  in  their  blood  and  flesh.  The  milk  of  such  cattle 
frequently  contains  the  bacilli,  whether  or  not  they  are  suffering  with 
tuberculosis  of  the  udder. 

Modes  of  Infection. — Hereditary  Transmission. — The  organism  may 
be  transmitted  to  the  offspring  either  by  the  spermatozoa,  by  the 
ovum,  or  by  the  blood  through  the  placenta.  Transmission  by  the 
sperm  has  not  been  definitely  substantiated;  while  possible,  it  seems 
improbable,  even  though  the  bacilli  have  been  found  in  the  semen. 
Transmission  by  the  ovum  is  unquestionably  possible,  animal  experi- 
mentation having  confirmed  it.  Transmission  by  blood  through  the 
placenta  is,  no  doubt,  the  most  common  method,  whether  the  placenta 
itself  be  the  seat  of  the  disease  or  not.  Transmission  by  either  one 
of  the  above  paths  would  account  for  the  occurrence  of  congenital 
tuberculosis. 

On  the  other  hand,  the  organism  may  be  conveyed  to  the  offsprmg 
by  the  parents,  and  remain  latent  until  such  time  as  the  child's  powers 
of  resistance  have  become  so  low  as  to  permit  the  disease  to  develop 
rapidly.  Nevertheless,  it  is  evident  that  in  both  modes  of  transmission 
the  organism  in  some  way  gains  access  to  the  body. 

The  chief  factors  in  favor  of  hereditary  tuberculosis  are  the  follow- 
ing: (1)  the  comparative  frequency  with  which  placental  tuberculosis 
has  been  found;  (2)  various  experiments  which  tend  to  show  how 
readily  the  offspring  may  become  infected.  The  fact  that  the  parents 
are  tuberculous,  or  the  mother  tuberculous,  does  not  necessarily  mean 
that  the  offspring  w411  be  likewise,  for  children  born  of  tuberculous 
parents  frequently  show  no  evidence  of  the  disease.  On  the  other 
hand,  just  as  many  manifest  signs  of  the  disease  early. 

Other  predisposing  factors  are  pathological  changes  which  may 
have  occm-red  within  those  tissues  which  are  the  most  frequent  site 
of  the  disease,  such  as  repeated  attacks  of  bronchopneumonia, 
pleurisy,  bronchitis,  chronic  inflammatory  conditions  which  affect 
the  mucous  membranes  of  the  respiratory  tract,  and  diseased  tonsils 
and   adenoids.      In   numerous   instances,    tuberculosis   follows   such 


720  THE  SPECIFIC  INFECTIOUS  DISEASES 

contagious  diseases  as  measles,  whooping-cough,  and  influenza, 
though,  unquestionably,  in  such  cases  the  tuberculous  infection  has 
been  latent. 

The  organisms  may  gam  access  to  the  body  either  by  the  respira- 
tory or  the  alimentary  tract,  and  children  living  in  homes  where 
members  of  the  family  are  suffering  with  the  disease  are  apt  to  con- 
tract it  by  inhalation;  particularly  is  this  so  if  they  are  of  the  age 
when  they  can  creep  about  the  floor,  and  thus  inhale  whatever 
particles  of  dust  may  be  on  the  sm-face  of  the  floor. 

The  most  common  cause  of  tuberculosis  in  children  is  contact 
with  persons  who  have  pulmonary  tuberculosis,  which  in  not  a  few 
cases  is  transmitted  by  kissing.  Next  to  its  transmission  by  the 
sputum,  tuberculosis  is  perhaps  most  often  spread  through  contam- 
inated milk.  The  clothing,  handkerchiefs,  carpets,  hangings,  and 
bedclothing  of  a  patient  with  tuberculosis  may  all,  for  a  short  time, 
be  carriers  of  the  disease. 

When  taken  into  the  alimentary  tract  the  bacillus  may  cause  a 
primary  tubercular  lesion  of  the  intestme,  resulting  in  involvement 
of  the  mesenteric  lymph  nodes;  or  it  may  penetrate  the  wall  of  the 
intestine,  and  gain  access  to  other  parts  of  the  body,  causing  a  gener- 
alized tubercular  infection.  Again,  it  has  been  proven  that  the 
organism  may  pass  directly  tlirough  the  mucous  membrane  of  the 
respiratory  tract  without  inciting  any  tubercular  lesion  of  the  mem- 
brane itself.    The  same  is  true  of  the  intestinal  mucosa. 

On  the  other  hand,  its  passage  through  such  membranes  is  greatly 
facilitated  if,  at  the  time,  the  membranes  are  the  seat  of  inflammation, 
whether  it  be  acute  or  chronic.  The  bacilli,  having  lodged  on  the 
surface  of  the  mucous  membrane,  are  taken  up  and  conveyed  by  the 
hmphatics  to  the  nearest  lymph  nodes,  where  they  are  either  arrested 
or  incite  some  tubercular  change  within  the  gland  itself;  or  they  may 
pass  on  through  the  lymphatics  to  involve  other  lymphatic  structures. 
The  glands  so  involved  become  markedly  inflamed  and  swollen,  and 
a  varying  degree  of  cell  proliferation  occurs,  which  eventually  results 
in  caseation.  The  bacilli  may  become  encapsulated,  and  remain 
latent  for  a  varying  period  of  time.  Later,  through  the  weakening 
of  the  individual  resistance,  or  by  symbiosis  with  another  germ,  they 
may  resume  their  activity  and  produce  the  disease.  It  may  be  seen, 
therefore,  that  the  resistance,  or  degree  of  bodily  proiectixe  yoicer, 
is  an  important  factor  in  arresting  or  promotmg  the  process. 

In  younger  children  the  bronchial  lymph  nodes  are  most  frequently 
involved  because  of  ready  access  to  them  by  way  of  the  bronchi. 
When  affected,  the}-  readily  midergo  caseation  and  softening,  and 
may  rupture  into  one  of  the  smaller  bronchi  or  a  bloodvessel,  thus 
gaining  access  to  the  lungs.  On  the  other  hand,  autopsies  have 
frequently  shown  the  lungs  to  be  affected  with  little  or  no  involve- 
ment of  the  bronchial  lymph  nodes.  Consequently,  it  is  not  neces- 
sary that  they  should  first  be  involved  in  order  that  the  disease  may 
extend  to  the  lungs. 


TUBERCULOSIS 


721 


The  tubercle,  which  is  the  pathological  lesion  produced  by  the 
organism,  is  an  inflammatory  circumscribed  growth,  varying  in  size 
from  that  of  a  pinhead,  or  less,  to  that  of  a  pea  or  larger.  It  is  grayish- 
yellow  in  color,  and  microscopically  is  seen  to  consist  of  an  abundance 
of  epithelial  cells,  in  the  centre  of  which  are  giant  cells.  The 
organisms  themselves  may  be  either  intracellular  or  extracellular. 
The  caseation  and  softening  are  the  direct  result  of  the  activity  of 
the  tubercle  bacillus.  After  the  formation  of  a  tubercle,  the  disease 
may  spread  by  contiguity,  in  that  other  tubercles  formed  nearby 
may  fuse  and  form  a  single  tubercle. 

Again,  the  infection  may  be  conveyed  by  the  secretions  and  excre- 
tions of  the  body,  such  as  the  lymphatic  stream,  which  may  convey 
infection  from  one  lymph  node  to  another,  or,  by  the  urine  carrying 
the  infection  from  the  kidneys,  the  primary  seat  of  the  disease,  to 
the  bladder.  The  organisms  may  gain  access  to  the  blood,  either 
directly  from  the  lymph  or  by  rupture  of  a  tubercle  into  a  bloodvessel, 
or  by  way  of^the  thoracic  duct  into  the  venous  circulation,  thence 
into  the  arterial  circulation.  Consequently,  in  either  way  the  disease 
may  be  generally  distributed  throughout  the  body.  In  children 
the  disease  is  met  with  in  increasing  numbers  as  they  advance  in 
years. 

The  frequency  with  which  tuberculosis  occurs,  as  shown  by 
autopsies,  is  given  by  Holt  in  a  table  as  follows: 


Institution. 

Age  of 
patient. 

Number  of 
autopsies. 

Number 

showing 

tuberculosis. 

Percentage 

of  cases  of 

tuberculosis. 

New  York  Infant  Asylum 

Nearly  all  up  to 

726 

56 

8.0 

Babies'  Hospital 

2|  years 
Nearly  all  under 

1000 

168 

16.8 

New     York      Foundling 
Hospital       .... 

3  years 
Nearly  all  under 

1000 

136 

13.6 

MilUer  (Munich) 

3  years 
Children    of    all 

500 

200 

40.0 

Hamburger  (Vienna) 

ages 
All  ages  up  to  14 

848 

335 

40.0 

Hamburger  (Vienna) 

years 
Including       only 
children    of    2 
years  and  less 

497 

120 

24.4 

Lesions. — The  lungs  are  the  organs  by  far  most  frequently 
aflfected;  next  are  the  bronchial  lymph  nodes,  the  spleen,  the  liver, 
the  pleurae,  the  kidneys,  the  brain,  the  intestines,  and  the  mesenteric 
lymph  nodes. 

The  bronchial  lymph  nodes  and  the  lungs  are  the  most  frequent 
seats  of  the  disease  in  early  infancy,  and  death  as  a  result  of  the 
pulmonary  process  occurs  most  often  during  the  first  two  years.  In 
many  of  the  remaining  cases  death  is  the  result  of  involvement  of 
the  brain.  At  this  age  other  forms  of  tuberculosis  are  rarely  the  cause 
of  death.  This  shows  that  tubercular  meningitis  is  most  frequently 
met  with  in  early  childhood  in  conjunction  with  pulmonary  tuber- 
46 


722  THE  SPECIFIC  INFECTIOUS  DISEASES 

culosis.  After  the  third  year  it  more  often  occurs  unaccompanied 
by  pulmonary  lesions,  and  is  usually  secondary  to  either  lymphatic 
or  bone  tuberculosis.  At  this  time  of  life,  too,  the  intestines  and 
peritoneum  are  more  often  affected  than  in  earlier  childhood. 

In  children  under  two  years  of  age  pulmonary  tuberculosis  is  more 
apt  to  be  diffused  throughout  the  lungs,  and  it  is  not  until  the  sixth 
or  seventh  year  that  the  pulmonary  lesions  of  childhood  resemble 
those  in  adult  life. 

Pulmonary  Forms. — The  younger  the  child  affected,  the  more 
diffuse  is  the  process  in  the  lungs  apt  to  be.  In  children  who  have 
passed  the  seventh  or  eighth  year,  the  pathological  changes  are  more 
likely  to  resemble  those  found  in  adults. 

Tuberculous  Bronchopneumonia. — This  is  by  far  the  most  common 
form  of  tuberculosis  met  with  in  young  children.  Its  course  is  usually 
subacute.  The  lesions  consist  of  caseous  areas  which,  in  some 
instances,  have  undergone  softening.  Areas  of  consolidation  are 
also  present.  As  a  rule  both  lungs  are  involved,  more  frequently 
the  upper  lobes  than  the  lower.  The  lung,  when  sectioned,  shows 
the  presence  of  minute  nodules  of  a  grayish-j'ellow  color,  varying 
in  size,  and  often  containing  pus,  while  others  which  have  not  under- 
gone softening  show  microscopically  giant  cells  and  tubercle  bacilli. 
The  nodules  are  usually  surrounded  by  an  area  of  bronchopneumonia. 
Frequently  a  cavity  is  present,  varymg  in  size  from  a  walnut  to  a 
hen's  egg.  A  tendency  to  encapsulation  of  the  tubercular  foci  is 
rare,  for  the  softening  usually  continues  until  death. 

Miliary  Tuberculosis. — Miliary  tubercles  are  present  in  the  lungs 
in  practically  all  cases  of  pulmonary  tuberculosis.  They  appear 
as  minute  yellowish-gray  tubercles  upon  the  surface,  in  most  instances 
in  the  neighborhood  of  an  old  tuberculous  lesion.  Except  for  the 
presence  of  these  minute  tubercles,  the  lung  frequently  appears  to 
be  normal,  while  in  other  cases  the  areas  between  the  tubercles  are 
congested  and  the  seat  of  bronchopneumonia. 

These  tubercles  are  usually  found  within  the  walls  of  the  smaller 
bronchi,  or  in  the  adventitia  or  intima  of  the  bloodvessels.  As  a 
result  of  the  presence  of  tubercle  bacilli  in  these  areas,  the  organisms 
are  usually  widely  scattered  thi'oughout  the  lungs .  The  bacilli  lodge  also 
in  various  organs  of  the  body,  and  produce  a  generalized  tuberculosis, 
having  gained  access  to  the  blood  either  by  perforation  of  the  lumen 
of  a  bloodvessel,  or  ulceration  of  a  caseous  mass  which  may  be  extra- 
vascular,  or  ulceration  of  a  lesion  within  the  bloodvessel  wall.  Where 
there  is  lung  involvement  the  pleura  usually  shows  the  presence  of 
tubercles  on  its  surface. 

Acute  Miliary  Tuberculosis. — This  form  of  tuberculosis  closely 
resembles  an  acute  infectious  disease.  It  may  occur  at  any  age, 
is  seldom,  if  ever,  primary,  and  usually  follows  some  focus  elsewhere 
in  the  body,  most  frequently  lesions  of  the  bronchial  lymph  nodes. 
It  may  be  either  active  or  latent  in  character,  and  readily  develops 
after  the  entrance  of  the  organisms  into  the  blood  stream,  w^hich  may 
occur  as  the  result  of  rupture  or  ulceration  of  the  diseased  lymph 


TUBERCULOSIS  1%^ 

node  into  a  bloodvessel.  Tubercles  make  their  appearance  through- 
out the  body  a  few  days  after  the  organisms  have  gained  access  to 
the  various  organs  by  way  of  the  blood  stream.  The  serous  surfaces, 
as  well  as  the  lungs,  spleen,  and  other  organs  become  affected.  This 
form  of  the  disease  occurs  most  frequently  between  the  ages  of 
twelve  and  twenty. 

Clinical  Varieties. — Three  clinical  forms  of  acute  tuberculosis  are 
usually  described: 

1.  The  general  or  typhoid  form,  which  gives  rise  to  symptoms 
closely  resembling  an  acute  general  infection. 

2.  The  pulmonary  form,  in  which  the  symptoms  are  chiefly 
pulmonary. 

3.  The  meningeal  form,  in  which  the  symptoms  are  cerebral  and 
spinal. 

1.  General  or  Typhoid  Form. — ^The  symptoms  in  this  form  are 
similar  in  many  ways  to  those  of  typhoid  fever,  for  which  it  is 
frequently  mistaken.  The  onset  is  usually  gradual,  with  progressive 
loss  in  weight,  weakness,  and  the  appearance  of  fever  which  gradually 
increases  in  intensity,  also  an  increase  in  the  pulse  rate.  The  limg 
symptoms  may  be  extremely  mild.  As  a  rule  there  is  a  moderate  bron- 
chitis. The  absence  of  nosebleed  and  of  diarrhea,  as  well  as  irreg- 
ularity of  the  temperature  and  a  tendency  to  cyanosis,  should  aid  m 
distinguishing  it  from  typhoid  fever.  Excessive  sweating,  more 
excessive  than  in  typhoid  fever,  is  characteristic.  The  spleen  is 
frequently  enlarged,  and  there  have  been  instances  of  hemorrhage 
from  the  bowel.  In  this  form  of  tuberculosis,  involvement  of  the 
choroid  coat  is  frequent. 

A  negative  Widal  test,  together  with  a  negative  blood  culture, 
will  also  assist  one  in  making  a  differential  diagnosis,  while  leuko- 
penia or  negative  leukocytosis  is  of  no  avail  in  that  it  is  frequently 
observed  in  uncomplicated  miliary  tuberculosis. 

Prognosis. — This  is,  as  a  rule,  unfavorable,  the  disease  terminating 
fatally  sooner  or  later.  The  duration  is  usually  from  one  to  three 
months,  but  it  may  sometimes  be  but  a  week  or  ten  days. 

Treatme7it. — Treatment  is  usually  s\Tiiptomatic.  The  fever  is 
abated  by  the  use  of  such  drugs  as  spirits  of  nitre  or  antipyrine.  Cough 
sedatives  are  frequently  necessary  in  view  of  the  fact  that  persistent 
cough  is  sometimes  one  of  the  most  annoying  symptoms.  Needless 
to  say,  food  of  the  most  nourishing  character  and  an  abundance  of 
fresh  air  are  essential  in  the  treatment. 

2.  Pulmonary  Form. — In  this  form  the  lung  symptoms  are  usually 
severe  from  the  beginning.  In  children  it  may  follow  the  infectious 
diseases,  such  as  measles  or  whooping-cough,  and  assumes  the  broncho- 
pneumonic  type.  In  older  children  there  is  copious  mucopurulent 
expectoration,  and  there  may  be  hemoptysis.  The  cough  is  more  or 
less  constant,  the  face  usually  flushed,  and  there  may  be  a  varying 
degree  of  cyanosis  about  the  lips  and  finger-nails. 

Owing  to  the   areas  of  bronchopneumonia  seen  in  children,  the 


724  THE  SPECIFIC  INFECTIOUS  DISEASES 

physical  signs  differ  somewhat  from  those  found  in  adults.  There 
may  be  areas  of  hyperresonance  or  vice  versa.  Upon  auscultation 
at  the  base  of  the  lungs,  the  breathing  may  be  of  high-pitched,  tubular 
character.  Rales  are  heard,  either  fine  and  crepitant,  or  sibilant  and 
sonorous.  The  temperature  in  this  pulmonary  form  of  the  disease 
usually  rises  to  103°  or  104°  F.,  the  pulse  becomes  rapid  and  weak, 
and  death  may  occur  within  a  short  period  of  time,  or  the  disease 
may  persist  for  a  year  or  longer.  In  some  cases  the  tubercle  bacillus 
may  be  found  in  the  sputum. 

Rapid  emaciation,  together  with  persistent  cough  and  fever,  ought 
to  arouse  suspicion  of  tubercular  disease,  especially  after  one  of  the 
minor  contagious  diseases.  Hemorrhage  from  the  lungs  is  not  uncom- 
mon, and  sometimes  may  be  the  only  suspicious  symptom.  In  the 
bronchopneumonic  type  a  differentiation  from  either  bronchopneu- 
monia or  simple  bronchitis  is  often  difficult.  In  the  true  pneumonic 
form,  which  rarely  affects  children,  an  early  diagnosis  is  practically 
impossible  because  of  the  close  resemblance  to  true  pneumonia  in 
its  earlier  stages.  Nevertheless,  in  pneumonia  an.  abatement  of  fever 
is  expected  by  the  tenth  or  twelfth  day  and,  should  it  not  occur,  one 
is  led  to  think  of  the  possibility  of  pneumonic  phthisis. 

Prognosis. — This,  unfortunately,  is  unfavorable,  the  disease  lasting 
usually  only  a  few  weeks  or  months. 

Treatment. — In  the  acute  stage,  the  treatment  is  chiefly  symptom- 
atic. The  subacute  and  chronic  stages  are  treated  the  same  as  chronic 
tuberculosis. 

3.  Meningeal  Form. — This  is  more  common  in  children  than  in 
adults,  occurring  most  frequently  between  the  ages  of  two  and  five, 
and  is  usually  secondary  to  some  tuberculous  lesion  elsewhere,  chiefly 
in  the  bronchial  lymphatic  glands.  Rarely  is  it  primary  in  the 
meninges,  but  the  meninges  about  the  base  of  the  brain  are  frequently 
involved.  Usually  certain  prodromal  symptoms  appear,  such  as 
progressive  loss  of  weight,  irritability,  and  loss  of  appetite.  Symptoms 
referable  to  the  meninges  suddenly  make  their  appearance;  there 
are  headache,  vomiting,  fever,  and  occasionally  convulsions.  The 
vomiting  is  characteristic  in  that  it  occurs  at  times  other  than  when 
food  is  taken. 

The  fever  rises  to  103°  or  104°  F.,  the  pulse,  at  first  rapid,  later 
becomes  slow  and  irregular.  Twitching  of  the  muscles  is  fairly  con- 
stant, and  the  pupils  are  contracted  during  the  early  stage  of  irritation. 
At  this  period  the  symptoms  resulting  from  irritation  usually  subside, 
but  there  is  marked  drowsiness,  and  at  times  retraction  of  the  head. 
The  pupils  become  dilated,  and  the  so-called  tache  cerebrale  appears. 
Finally  the  stage  of  paralysis  sets  in,  the  child  becomes  markedly 
comatose,  and  spasmodic  contractions  of  groups  of  muscles  may  occur. 
The  pulse  becomes  rapid  and  feeble,  and  there  are  symptoms  of  the 
so-called  typhoid  state — namely,  delirium,  dry  coated  tongue,  and 
incontinence  of  urine  and  feces.  The  duration  of  the  disease  varies 
from  two  days  to  a  month  or  more. 


TUBERCULOSIS  725 

Diagnosis. — The  diagnosis  is  usually  not  difficult,  especially  if 
a  previously  existing  focus  can  be  found  elsewhere  in  the  body, 
together  with  the  characteristic  train  of  symptoms  A  lumbar 
puncture  may  reveal  the  presence  of  the  bacilli  and  an  abundance 
of  small  mononuclear  lymphocytes,  also  an  increase  in  the  cerebro- 
spinal pressure,  which  may  become  as  high  as  48  to  52  mm.  Hg.  Of 
course  the  presence  of  the  tubercle  bacillus  in  the  cerebrospinal  fluid 
makes  the  diagnosis  positive. 

Meningeal  tuberculosis  is  chiefly  to  be  distinguished  from  menin- 
gitis due  to  causes  other  than  the  tubercle  bacillus.  The  presence  of 
a  tuberculous  lesion  elsewhere  in  the  body  is  of  great  aid.  Menin- 
gitis resulting  from  syphilis  is  usually  chronic  in  form,  and  rarely 
acute,  and  is  apt  to  be  localized  to  one  side.  The  presence  of  tubercles 
in  the  choroid  is  diagnostic. 

Prognosis. — This  form  of  the  disease  is  practically  always  fatal. 
In  instances  where  cures  have  been  reported,  there  has  usually  been 
an  error  in  diagnosis.  However,  recovery  has  apparently  occurred 
in  a  few  cases. 

Treatment.— -Though  the  treatment  is  limited,  every  effort  should 
be  made  to  combat  the  symptoms,  inasmuch  as  the  disease  fre- 
quently proves  to  be  other  than  tubercular,  and  a  cure  may  be 
effected.  The  headache,  which  is  so  intense,  is  often  relieved  by 
lumbar  puncture,  and  narcotics  should  be  used  freely  during  the  stage 
of  irritation.    Operations  upon  the  skull  have  so  far  been  of  no  avail. 

Chronic  Tuberculosis. — This  form  of  the  disease  is  usually  met 
with  after  the  fourth  Vear.  It  is  contracted  either  by  inhalation  or 
by  way  of  the  alimentary  tract,  or  is  secondary  to  a  previously  exist- 
ing tulDerculosis,  chiefly  tuberculosis  of  the  bronchial  lymph  nodes. 

Symptoms. — The  onset  is  slow,  and  is  accompanied  by  loss  in  weight 
and  a  cough  which  becomes  more  or  less  persistent,  together  with 
a  rise  in  temperature  which  often  goes  unnoticed.  In  the  early  stage 
of  the  disease  the  pulmonary  symptoms  are  either  vague  in  character 
or  absent  altogether.  Frequently  the  organisms  may  be  found  in 
the  sputum  prior  to  any  lung  manifestation.  By  auscultation  rales 
may  often  be  heard  over  various  parts  of  the  lungs.  This  is  chiefly 
so  in  younger  children,  because  the  disease  in  them  does  not  neces- 
sarily begin  at  the  apices  of  the  lungs,  as  it  so  frequently  does  in 
adults.     Later  definite  physical  signs  render  a  diagnosis  possible. 

The  chest  becomes  flattened,  there  are  areas  of  dulness  on  percus- 
sion, and  rales,  frequently  scattered,  are  heard  over  the  chest.  As 
the  process  continues  cavities  form,  evidences  of  which  are  the  char- 
acter of  the  breathing,  characteristic  metallic  rales,  and  a  tympanitic 
note  on  percussion  over  the  broken-dow^n  areas.  At  this  time  the 
loss  in  weight  is  marked,  and  the  fever  becomes  irregular.  Such  a 
child  is  extremely  susceptible  to  intercurrent  infections. 

The  diagnosis  of  the  disease  in  its  early  stages  is  extremely  impor- 
tant, for  upon  this  alone,  in  the  majority  of  instances,  depends 
the  question  whether  or  not  a  cure  can  be  effected.     In  all  cases  in 


726  THE  SPECIFIC  INFECTIOUS  DISEASES 

which  there  is  constant  cough  with  loss  in  weight  and  fever  of  irregu- 
lar t\npe,  suspicion  should  be  aroused,  and  the  chest  frequently  exam- 
ined for  signs  of  the  disease,  since  on  these  depends  the  prognosis. 

General  Tuberculosis. — ^In  many  cases  of  tuberculosis  in  infants 
the  early  signs  and  symptoms  are  those  of  marasmus  alone,  and  tuber- 
culosis is  not  even  suspected  until  toward  the  end  of  the  illness.  Not 
a  few  cases  of  tuberculosis  in  infants  are  first  recognized  at  autopsy, 
because  of  the  lack  during  life  of  any  symptoms  or  physical  signs 
referable  to  the  disease. 

As  a  rule  these  infants  steadily  lose  weight  and  strength,  and  exhibit 
anemia  for  which  there  is  no  apparent  cause.  Cough  and  fever  may 
be  absent  at  first,  although  toward  the  end  of  the  disease  there  is, 
as  a  rule,  a  daily  temperature  range  of  100°  to  102°  F.,  the  fever  being 
either  constant  or  intermittent. 

Disturbances  of  the  gastro-intestinal  tract  are  the  most  prominent 
features  of  the  disease,  and  there  is  usually  indigestion,  malassimila- 
tion,  vomiting,  and  diarrhea,  although  these  symptoms  are  rarely 
due  to  involvement  of  the  stomach  or  intestines.    Late  in  the  disease 


Fig.  71. — General  tuberculosis  in  a  child  aged  two  and  a  half  years. 

a  cough  develops,  the  respirations  are  abnormally  rapid,  and  the 
lungs  show  evidences  of  bronchitis  which  is  followed  by  bronchopneu- 
moni'a. 

The  terminal  symptoms  are  dyspnea,  cyanosis,  marked  asthenia, 
emaciation,  and  prostration,  death  resulting  either  from  the  pulmonary 
lesion,  menigeal  involvement,  or  general  exhaustion. 

Tuberculosis  of  the  Glands. — Lymphatic  Glands,  Bronchial. — The 
glands  most  frequently  affected  in  early  infancy  are  the  bronchial 
lymph  nodes,  comprising  those  about  the  trachea  and  its  bifurcation, 
and  those  which  accompany  the  bronchi  into  the  lungs.  Usually 
they  are  all  affected  at  the  same  time.  The  changes  which  occur 
within  the  glands  are  identical  with  the  changes  elsewhere  resulting 
from  the  presence  of  the  organism.  At  times  they  may  undergo 
suppuration,  but  not  as  frequently  as  do  the  cervical  lymphatics 
when  involved. 

Suppuration  of  the  bronchial  glands  is  most  common  during  infancy, 
but  calcification  of  these  glands  rarely  occurs  at  this  age.  When 
suppuration  takes  place,  the  escape  of  pus  may  cause  a  mediastinal 
or  retropharyngeal  abscess. 


TUBERCULOSIS  727 

Other  sequelae  of  suppurative  tuberculous  bronchial  lymphadenitis 
are  compression  and  ulceration  of  the  trachea  and  esophagus,  acute 
miliary  tuberculosis,  and  hemorrhage  from  the  erosion  of  a  large  blood- 
vessel. When  the  glands  which  have  undergone  caseation  become 
encapsulated,  few  of  these  dire  mishaps  occur,  and  the  infection  may 
be  locked  up  in  the  glands  for  years,  producing  no  symptoms,  and 
doing  no  apparent  harm. 

Cervical  Glands. — In  90  per  cent,  of  all  cases  of  tuberculous  lymphad- 
enitis the  cervical  glands  are  involved,  and  less  frequently  the  othet 
superficial  lymph  nodes  of  the  body.  Caseation  of  the  external  lym- 
phatics in  the  neck,  groin,  axilla,  and  other  regions  of  the  body  is  usually 
followed  by  ulceration,  and  the  discharge  of  pus  externally. 

Mesenteric  Glands. — ^The  same  pathological  changes  occur  in  these 
glands  as  in  other  lymphatic  glands.  Softening  may  occur  and,  from 
leakage  or  rupture,  produce  a  localized  peritonitis.  Enlargement  of 
this  group  of  glands  may  give  rise  to  symptoms  which  are  the  result 
of  pressure  upon  the  vena  cava,  the  portal  vein,  or  thoracic  duct. 
About  60  per  cent,  of  all  tuberculous  cases  in  children  show  invasion 
of  the  mesenteric  glands.  They  are  rarely  involved  independently 
of  the  bronchial  lymph  nodes,  and  only  occasionally  is  the  condition 
sufficiently  developed  to  be  recognized  independently  of  tuberculous 
peritonitis. 

Syni'ptoms. — ^The  symptoms  of  abdominal  tuberculosis  are  disten- 
tion and  pain  in  the  abdomen,  intestinal  indigestion,  flatulence, 
diarrhea,  persistent  elevation  of  temperature,  and  slow  but  progres- 
sive emaciation.  Upon  abdominal  examination  the  glands  may  some- 
times be  palpated,  if  relaxation  of  the  abdominal  walls  can  be  secm-ed. 
Masses  may  be  felt  in  both  iliac  fossse,  and  quite  a  prominent  group 
palpated  in  the  region  of  the  appendix,  which  forms  a  tumor. 

Inasmuch  as  the  symptoms  somewhat  resemble  those  of  chronic 
appendicitis,  a  rectal  examination  may  be  necessary  to  determine 
whether  or  not  there  is  enlargement  of  the  appendix.  The  outlook 
in  the  cases  which  are  sufficiently  developed  to  be  diagnosed  is,  as 
a  rule,  unfavorable.  Recovery  may  take  place,  however,  with  surpris- 
ing frequency,  so  that  hope  should  never  be  abandoned.  Still  recom- 
mends laparotomy,  with  removal  of  the  infected  glands  and  the 
breaking  up  of  adhesions,  in  addition  to  the  routine  treatment  for 
all  forms  of  tuberculosis. 

Pleura. — Rarely  does  the  pleura  escape  in  tuberculosis  of  the  lungs. 
In  the  generalized  form  of  the  disease  it  may  be  the  seat  of  numerous 
miliary  tubercles.  Thickening  of  the  pleiua,  together  with  adhesions 
over  a  portion  of  the  lung  involved,  is  quite  frequent.  Serous  effusions 
which  are  often  sacculated  are  not  uncommon  in  infants  and  young 
children;  empyema  may  occur,  but  is  rare.  The  fibrous  adhesions 
which  form  in  tuberculous  pleurisy  may  cause  marked  interference 
with  pulmonary  expansion. 

Heart. — The  pericardium  is  rarely  affected  save  in  acute  general 
miliary  tuberculosis,  when  the  visceral  surface  may  be  dotted  with  a 


728 


THE  SPECIFIC  INFECTIOUS  DISEASES 


few  scattered   tubercles.     Tuberculous   lesions   of  the  endocardium 
and  myocardium  are  practically  unknown. 

Brain. — In  very  early  infancy  and  prior  to  the  third  year  the  brain 
is  not  uncommonly  affected,  but  after  this  it  is  less  frequently  attacked. 
Minute  miliary  tubercles  or  caseous  nodules  may  be  present.    About 

70  per  cent,  of  the  cases  of  tuberculous 
meningitis  are  seen  between  the  ages 
of  one  and  five  years. 

Liver. — This  organ  usually  becomes 
affected  in  general  tuberculosis,  num- 
erous miliary  tubercles  forming  on  its 
surface  and  throughout  its  interior. 
Spleen. — When  involved,  practically 
the  same  changes  are  found  here  as 
within  the  liver — namely,  miliary 
tubercles  on  its  surface  and  throughout 
its  interior.  It  is  rarely  enlarged  save 
in  instances  where  nodules  have  formed. 
Intestines. — In  infancy  involvement 
of  the  intestines  is  less  common  than 
in  later  childhood,  but  usually  the 
small  intestine  is  the  seat  of  the  dis- 
ease. Minute  nodules  are  deposited 
on  the  surface  of  the  bowel.  Ulcers 
are  frequently  found,  especially  in  the 
neighborhood  of  Peyer's  patches,  usu- 
ally extending  only  into  the  mucosa, 
but,  if  of  long  duration,  they  may 
involve  other  coats  of  the  bowel.  As 
a  result  of  this  ulceration  perforation 
or  cicatrization  may  take  place  and 
cause  a  narrowing  of  the  lumen  of  the 
intestine. 

Peritoneum. — Rarely  is  the  perito- 
neum affected  in  early  childhood,  but 
in  general  tuberculosis  of  older  children 
it  may  be  the  seat  of  miliary  tubercles 
or  tuberculous  nodules. 
Kidney. — ]\Iiliary  tubercles  or  nodules  may  be  found  in  the  kidneys 
accompanying  generalized  tuberculosis,   although  rarely.     Tubercu- 
losis elsewhere  in  the  genito-urinary  tract  is  most  uncommon,  although 
several  cases  of  involvement  of  the  testicle  have  been  reported. 

Prognosis. — The  prognosis  in  tuberculosis  of  children  depends 
to  a  great  extent  upon  the  location  of  the  disease.  Pulmonary  lesions 
are  always  serious,  and  well  developed  foci  usually  prove  fatal.  Gland- 
ular tuberculosis  is  in  many  instances  followed  by  recovery.  The 
environment,  climate,  care,  and  treatment  of  a  child  with  tubercu- 
lous lesions  anywhere  in  the  body  also  influence  the  prognosis  to 
a  great  extent. 


Fig.  72.  —  Tuberculous  perito- 
nitis, tuberculous  spondylitis,  and 
tuberculous  glands  of  the  neck  in  a 
boy,  aged  seven  years. 


TUBERCULOSIS  729 

Prophylaxis. — The  prevention  of  tuberculosis  is  a  most  important, 
and  at  the  same  time  a  very  difficult  problem,  especially  among 
the  poor.  It  can  be  accomplished,  however,  if  tubercle  bacilli  from 
every  source  are  destroyed  and  needless  exposure  is  avoided.  Sputum 
from  tuberculous  patients  should  be  carefully  collected  and  destroyed, 
since  this  is  probably  the  most  frequent  source  of  tuberculous  infec- 
tion. The  living  quarters  of  tuberculous  patients  should  be  disin- 
fected before  children  or  any  other  persons  are  allowed  to  enter  them. 
A  tuberculous  mother  should  neither  nurse  her  child  nor  kiss  it  upon 
the  mouth,  and  the  less  she  fondles  it  the  better.  No  child  should 
be  allowed  to  associate  in  any  way  with  tuberculous  persons,  for  it 
has  been  demonstrated  that  tuberculous  spray  is  projected  several 
feet  when  a  consumptive  coughs. 

Systematic  school  inspection  is  a  great  aid  in  differentiating  tuber- 
culous children  from  healthy  ones.  If  the  parents  are  tuberculous 
the  utmost  precautions  are  necessary  in  the  home  to  prevent  infection. 
The  milk  supply  is  an  important  consideration,  and,  if  not  obtained 
from  a  herd  that  has  been  tested  with  tuberculin,  the  milk  should 
be  pasteurized  before  giving  it  to  children. 

Since  delicate  children  and  those  with  chronic  catarrh  of  the  upper 
respiratory  tract  are  especially  liable  to  tuberculosis,  they  should 
be  carefully  protected  from  exposure  and  should  lead  an  outdoor 
life,  preferably  in  the  country,  fresh  air  and  sunshine  being  the  two 
great  preventives  of  this  disease.  These  precautions  are  especially 
applicable  to  children  whose  parents  are  tuberculous. 

Tuberculin  Tests. — In  view  of  recent  claims  of  benefit  to  be  attrib- 
uted to  the  use  of  old  tuberculin  as  an  aid  to  diagnosis,  it  seems 
expedient  to  give  it  brief  mention.  The  preparation  itself  is  a  fluid, 
brownish  in  color,  consisting  of  the  filtrate  from  a  culture  of  tubercle 
bacilli  in  glycerin  bouillon  after  the  bacilli  have  been  filtered  off. 
In  short,  it  consists  chiefly  of  the  products  of  the  bacillus.  When 
used,  it  is  diluted  with  water  and  injected  subcutaneously,  with  all 
necessary  asceptic  precautions.  The  amount  to  be  used  is  deter- 
mined by  the  condition  of  the  patient,  and  where  there  are  evidences 
of  tuberculous  involvement  should  be  extremely  small. 

The  reaction  following  its  injection  manifests  itself  generally  by 
a  slow  rise  in  temperature,  for  six  to  eight  hours  after  the  injection, 
followed  by  a  rapid  rise  during  the  next  few  hours,  and  then  a  gradual 
decline.  During  the  rise  in  temperature  there  may  be  such  symptoms 
as  headache,  vomiting,  and  the  like.  A  rise  in  rectal  temperature  to 
99^°  F.  is  considered  positive. 

It  also  produces  a  reaction  in  the  tissues  affected  by  the  disease, 
causing  them  to  become  congested,  and  to  evince  changes  reactionary 
in  type.  Lastly  there  is  a  reaction  about  the  site  of  the  injec- 
tion, chiefly  a  hyperemia,  which  makes  its  appearance  six  to  eight 
hours  after  the  injection,  and  may  last  from  a  few  to  several  days. 
Tuberculin  is  used  cutaneously,  subcutaneously,  and  in  the  eye  in 
order  to  detect  early,  latent,  or  doubtful  cases  of  tuberculosis.     The 


730  THE  SPECIFIC  INFECTIOUS  DISEASES 

cutaneous  test  is,  perhaps,  the  one  most  extensively  employed,  and 
the  eye  test  least  of  all.  In  children  these  methods  of  determining 
tuberculosis  are  especially  valuable. 

Cutaneous. — ^The  cutaneous  test,  or  von  Pirquet  reaction,  is  prac- 
tically a  vaccmation  with  tuberculin.  The  forearm  is  the  site  chosen, 
and  after  carefully  washing  the  skm  with  alcohol  or  ether  a  small 
superficial  scarification  is  made,  preferably  with  a  special  scarifier, 
and  a  drop  of  undiluted  tuberculm  is  then  applied.  It  has  been  our 
practise  to  make  two  such  vaccinations,  and  then  to  scarify  an  area 
between  them  to  which  no  tuberculin  is  applied,  this  untreated  area 
bemg  used  as  a  control. 

The  arm  should  then  be  held  by  the  parent,  or  nurse,  until  the 
scarified  areas  are  quite  dry,  so  that  there  will  be  no  contamination. 
In  some  instances  the  arm  may  be  dressed  with  a  piece  of  sterile 
gauze. 

In  active  cases  the  reaction  is  noticeable  within  twenty-four  hours, 
and  consists  of  a  red  areola  around  the  points  of  inoculation.  A  small 
red  papule  also  forms,  but  disappears  in  the  coiu-se  of  a  few  days  or 
a  week,  the  size  of  the  inflammatory  areola  being  an  indication  of 
the  degree  of  the  reaction. 

The  untreated  scarification  should  heal  with  no  sign  of  mflam- 
mation.  The  inflammatory  areolas  usually  begin  to  fade  the  second 
or  third  day,  but  marked  reactions  may  be  visible  for  as  long  as  ten 
days.  Infiltration  of  the  skin,  and  even  mduration,  is  sometimes 
observed,  and  in  rare  cases  vesiculation. 

This  test  is  very  valuable  in  infants  and  children  under  two  years 
of  age,  and  a  positive  reaction  may  be  regarded  as  significant  of 
tuberculosis  in  every  case.  A  negative  reaction  indicates  the  absence 
of  any  tuberculous  focus.  These  findings  are  invariably  supported 
by  physical  examination  and  laboratory  and  autopsy  findings,  but 
no  test  for  tuberculosis  is  as  conclusive  as  is  the  detection  of  the 
tubercle  bacillus  in  the  cerebrospinal  fluid,  sputum,  or  elsewhere. 

The  reaction  fails  to  appear  in  the  eruptive  stage  of  measles,  and 
is  very  um-eliable  in  cachectic  conditions,  scarlet  fever,  diphtheria, 
and  t\T3hoid  fever.  A  second  test  is  advisable  when  the  first  test 
is  negative. 

Subcutaneous. — The  subcutaneous  test,  or  stick  reaction  of  Ham- 
burger, consists  in  the  injection  of  yito  to  xoVo  of  a  milligram 
of  tuberculin  beneath  the  skin  of  the  forearm.  Two  reactions  are 
observed,  one  at  the  point  where  the  needle  penetrates  the  skin,  and 
a  larger  area  where  the  tuberculin  is  injected.  The  reaction,  which 
comprises  swelling,  redness,  and  induration,  may  appear  in  24  hours, 
and  last  for  five  or  six  days. 

Moro  Test. — The  ]\Ioro  test  consists  in  applying  1  grain  of  an 
ointment  made  of  equal  parts  of  old  tuberculin  and  anhydrous  lano- 
line  to  the  epigastric  or  submammary  region.  The  finger  used  for 
this  inunction  should  be  protected  by  a  rubber  cot,  and  the  salve 
spread  only  over  an  area  two  inches  in  diameter,  which  has  previously 


TUBERCULOSIS  731 

been  carefully  cleansed.  A  control  may  be  made  by  rubbing  plain 
lanoline  upon  an  area  adjacent  to  the  inoculated  skin. 

The  reaction  consists  in  a  papular  or  vesicular  eruption  which 
appears  in  twelve  to  forty-eight  hours,  and  persists  for  several  days. 
In  severe  cases  it  is  followed  by  pigmentation. 

Eye  Reaction. — The  ophthalmic  reaction,  or  Calmette  test,  is  per- 
formed by  dropping  in  the  eye  0.5  per  cent,  solution  of  precipitated 
tuberculin  in  sterile  salt  solution.  Within  six  to  twelve  hours  there 
is  swelling,  redness,  and  injection  of  the  palpebral  conjunctiva  with 
a  slight  or  copious  mucofibrinous  secretion.  The  instillation  should 
be  done  at  night  so  that  the  reaction  may  be  observed  the  following  day. 

The  mflammation  in  the  eye  subsides  in  from  one  to  three  days, 
but  only  healthy  eyes  should  be  injected,  and  any  sign  of  tuberculosis 
about  the  eye  is  a  special  contra- mdication.  The  child's  hands  must 
be  kept  away  from  the  eyes  as  long  as  they  are  inflamed.  In  older 
children,  and  in  out-patient  practice,  this  test  is  not  recommended; 
and,  as  injury  to  the  eye  has  occasionally  occurred,  the  ophthalmic 
test  is  now  very  little  employed. 

Numerous  modifications  have  been  advanced  since  the  von  Pirquet 
reaction  came  into  use,  such  as  the  application  of  ointment  containmg 
tuberculin,  this  being  known  as  the  salve  reaction.  None  of  these, 
however,  has  proven  as  positive  and  conclusive  in  its  reaction  as 
the  von  Pirquet. 

The  following  statistics  are  given  by  Holt  to  show  the  relation  of 
age  to  tuberculin  -tests  in  the  child : 


Number  of 

Per  cent. 

of 

Number  of 

Per  cent,  of 

Age. 

cases. 

tuberculosis. 

tests. 

reactions. 

Under  3  months 

105 

4 

147 

0 

3  to    6 

73 

18 

64 

5 

6  to  12 

140 

23 

67 

16 

2  years     . 

179 

40 

88 

24 

3  to    4      "        .      . 

175 

60 

127 

37 

5  to    6       "        .      . 

67 

56 

101 

53 

7  to  10      "        .      . 

65 

63 

182 

57 

11  to  14      "        .      . 

44 

70 

100 

68 

Over  14       "        .       . 

112 

90 

848  40  988  41 

Treatment. — Of  chief  importance  in  the  treatment  of  the  disease 
are  the  hygienic  and  dietetic  measures.  Such  a  child  should  be  kept 
out  of  doors  as  much  as  possible.  It  is  frequently  necessary  to  try 
a  change  of  climate,  such  as  sea  air  in  the  very  early  stages,  and  higher 
altitudes  later.  Foods  of  the  most  nourishing  type,  highly  abundant 
in  fats,  are  to  be  recommended.  Milk  is  the  best  staple  of  the  diet,  and 
cream  is  almost  as  beneficial  as  cod-liver  oil,  if  digested  and  assimi- 
lated in  sufficient  quantities.  All  alcoholic  stimulants  should  be 
avoided,  unless  absolutely  necessary.  An  abundance  of  sleep  and 
rest  is  important,  and  moderate  exercise  should  be  taken.  The  admm- 
istration  of  drugs  should  be  delayed  until  it  becomes  absolutely  neces- 
sary, and  then  they  should  be  used  cautiously  in  order  to  prevent  any 
irritation  of  the  stomach. 


732  THE  SPECIFIC  INFECTIOUS  DISEASES 

Tuberculin  is  recommended  by  some  clinicians.  It  should  be 
carefully  used,  beginning  with  extremely  small  doses,  such  as  -^-^ 
of  a  mg.,  and  these  mcreased  when  there  is  no  reaction. 

Other  symptoms  which  necessitate  consideration  are  the  night- 
sweats  which  so  frequently  cause  extreme  weakness.  The  use  of 
diluted  vinegar,  applied  to  the  surface  of  the  body  in  the  form  of 
a  sponge  bath,  is  frequently  followed  by  relief.  The  fever  should  be 
combated  as  is  best  possible.  Antipyretics,  such  as  antipyrin,  are 
sometimes  of  value.  Hemoptysis  is  best  treated  by  rest  in  bed  and 
the  use  of  morphin,  either  hypodermically  or  by  mouth,  in  doses 
of  4V  to  2^0"  of  a  grain. 

Cod-liver  oil,  if  tolerated  by  the  stomach,  is  very  valuable  for 
the  upbuilding  of  the  child's  general  health,  and  may  be  given  in 
^  to  1  dram  doses,  three  or  four  times  daily.  It  gives  the  best  results 
when  taken  after  meals.  The  syrup  of  the  iodide  of  iron  is  especially 
beneficial  in  glandular  tuberculosis,  given  in  5-  to  20-drop  doses  after 
meals. 

In  tuberculous  adentitis,  iodine  may  be  used  locally  in  the  form  of 
a  5  to  10  per  cent,  ointment,  with  lanoline  as  a  base.  A  10  per  cent, 
guaiacol  ointment  is  also  valuable  in  some  cases,  and  in  children  the 
local  use  of  this  drug  is  followed  by  better  results  than  its  internal 
administration.  Fowler's  solution  is  a  good  tonic,  given  in  1-  to 
3-drop  doses  three  times  a  day  combined  with  the  syrup  of  ■  hypo- 
phosphites  or  elixir  of  glycerophosphates. 

Cresote  may  be  given  in  1-  to  2-minim  doses,  in  pill,  in  an  emul- 
sion with  cod-liver  oil,  or  by  inhalation.  Inunctions  of  cod-liver 
and  other  nutritive  oils  are  advisable  when  internal  medication  is 
contraindicated  by  intolerance  of  the  gastro-intestinal  tract. 


MALARIA. 

Malaria  is  an  infectious  disease,  due  to  a  specific  organism  known 
as  the  Plasmodium  malarise,  and  characterized  by  fever  either  of 
intermittent  or  remittent  type,  or  by  poisoning  of  a  chronic  type 
which  results  in  anemia  and  splenic  enlargement. 

Etiology. — The  parasite  was  discovered,  in  1880,  by  Laveran,  and  in 
1897  the  mode  of  transmission  was  demonstrated  by  Ross.  The 
Plasmodium  is  distinctly  a  blood  parasite,  which  gains  access  to  the 
blood  stream  through  the  sting  of  mosquitoes,  particularly  the  female 
Anopheles., 

Malaria  is  common  in  infants  and  young  children  in  regions  where 
the  disease  is  prevalent",  and  may  occur  in  utero.  One  attack  confers 
no  immunity  from  future  attacks. 

Distribution. — The  disease  is  diminishing  everywhere,  being  now 
chiefly  seen  in  southern  Russia  and  Italy.  It  is  quite  prevalent  in 
India,  also  in  Africa,  where  it  is  of  extremely  pernicious  type.  In  the 
United  States  it  is  steadily  disappearing,  though  it  still  prevails  in  some 


MALARIA  733 

sections  of  the  South,  and  during  the  spring  and  autumn  months  is 
very  prevalent  in  the  tropics. 

The  Parasite. — The  parasite  gains  access  to  the  stomach  of  the 
mosquito  through  the  blood  stream  and  forms  minute  cysts,  the 
contents  of  which  become  transformed  into  crescent-shaped  germs 
which,  after  the  eruption  of  the  cysts,  pass  to  the  salivary  glands  of 
the  mosquito,  and  are  readily  transmitted  to  the  human  being  by  the 
bite  of  the  mosquito.  These  young  parasites  enter  into  the  human 
blood  corpuscles,  and  there  undergo  a  cycle  of  development. 

There  are  two  groups  of  organisms:  (1)  the  large  parasite,  con- 
sisting of  two  types — the  tertian  and  quartan  organisms;  (2)  the  small 
parasite  of  tropical  fevers,  known  as  the  estivo-autumnal  parasite. 

Large  Parasites. — The  tertian  is  by  far  the  most  common  of  the  large 
parasites,  and  passes  through  its  cycle  within  forty-eight  hours,  giving 
rise  to  paroxysms  on  alternate  days,  provided  there  be  but  a  single 
infection.  Such  paroxysms  occur  during  segmentation,  and  last  from 
twelve  to  fourteen  hours.  Should  there  be  a  double  infection,  a 
paroxysm  occurs  daily  (quotidian  fever),  and  upon  examination  of 
the  blood  two  distinct  groups  of  organisms  will  be  found.  In  rare 
cases  there  may  be  more  than  two  infections. 

The  parasite  is  non-pigmented  and  egg-shaped.  Sometimes  a 
small  swelling  is  perceptible  along  half  of  the  ring,  giving  it  the  appear- 
ance of  a  signet  ring.  It  possesses  in  marked  degree  the  power  of 
ameboid  movement,  and  thus  undergoes  frecpent  changes  of  shape, 
and  position.  Occasionally  the  parasite  undergoes  another  form  of 
development,  with  ameboid  processes  different  from  the  rings.  The 
small  tertian  rings  enlarge  within  twenty-four  hours,  obtaining  their 
pigment  granules  from  the  hemoglobin  of  the  corpuscles,  which  become 
much  enlarged  and  fade.  Within  another  twelve  hours  the  parasites 
are  converted  into  disks,  bluish  in  color  which,  prior  to  the  paroxysm, 
divide  into  minute  egg-shaped  bodies  which  are  the  young  parasites. 
During  this  latter  cycle  the  corpuscle  becomes  progressively  paler, 
and  finally  loses  its  outline  completely.  Each  segment  separates 
individually  as  a  hyaline  organism,  and  gains  access  to  other  corpuscles. 

Other  forms  of  the  tertian  parasite  are  the  extracellular  A'arieties, 
which  consist  of  two  types,  the  gametocytes  and  the  degeneration 
forms.  The  latter  are  merely  those  types  which  have  escaped  from 
their  cells  and  have  died.  The  gametocytes  correspond  to  the  crescents 
of  the  estivo-autumnal  form,  and  occur  after  there  have  been  frequent 
attacks  of  fever,  appearing  in  the  blood  as  extremely  large  organisms. 
Often  they  are  double  the  size  of  a  red  corpuscle,  and  contain  pig- 
ment which  is  more  or  less  diffusely  ^scattered.  They  never  show 
segmentative  changes,  but  are  extremely  active,  and  intended  for 
sexual  development. 

Quartan  Parasites. — This  form  differs  from  the  tertian  variety  in 
that  it  requires  seventy-two  hours  for  its  cycle  of  development  instead 
of  forty-eight  hours,  thus  causing  the  paroxysms  to  occur  on  the  fourth 
day.     Should  two  groups  be  present,  there  will  be  paroxysms  on  two 


734  THE  SPECIFIC  INFECTIOUS  DISEASES 

succeeding  days,  followed  by  a  day  of  rest.  If  three  groups  are 
present,  the  fever  will  be  quotidian.  In  the  early  stages  the  parasite 
cannot  be  differentiated  from  the  tertian  variety,  but  upon  the  appear- 
ance of  the  pigment  it  is  found  to  be  coarser  in  type,  and  is  capable  of 
less  activity. 

Coincident  with  the  growth  of  the  parasite  the  corpuscle  shrinks  and 
becomes  small,  and  its  margin  becomes  irregular  in  outline.  The 
parasitic  protoplasm  has  a  waxy  appearance,  consequently  is  more 
refractive  than  the  tertian  varieties.  At  the  end  of  twenty-four 
hours  the  blood  cell  becomes  crenated,  brassy  in  color,  and  the  pig- 
ment loses  its  activity.  At  the  end  of  sixty  hours  the  outline  of  the 
cell  is  completely  lost,  the  organism  is  motionless,  and  pigment  collects 
about  the  periphery. 

Later  the  pigment  migrates  toward  the  centre,  eventually  collecting 
there,  and  segmentation  begins,  eight  to  twelve  young  parasites  being 
formed.  Here  also  gametes  and  spheres  may  be  seen,  but  differ  from 
those  of  the  tertian  type  by  their  smaller  size. 

Estivo-autumnal  Parasites. — This  form,  met  with  in  the  tropics,  is 
the  most  dangerous  of  the  three  types  of  plasmodia.  Early  in  the 
infection  the  grouping  is  distinct,  but  they  soon  separate,  and  at 
different  stages  of  development  are  later  found  in  the  internal  organs. 
The  course  and  duration  of  the  cycle  is  not  always  the  same,  therefore 
the  fever  is  more  or  less  continuous,  loses  its  intermittency,  and 
sometimes  closely  resembles  the  fever  of  typhoid. 

In  the  very  early  stages,  the  development  of  hyaline  forms  differs 
but  little  from  that  of  the  tertian  and  quartan  types.  They  are 
very  refractive,  and  can  be  readily  seen.  The  pigment  within  the 
bodies  is  of  fine  type.  The  blood  cell  is  markedly  enlarged  by  the 
parasite,  frequently  becoming  crenated,  and  is  brassy  in  appearance 
during  the  very  early  stages  of  development,  but  gradually  ceases  to 
exist  in  the  peripheral  circulation,  and  remains  chiefly  within  the 
spleen.  At  times,  the  plasmodium  may  be  found  within  the 
peripheral  blood  stream,  in  all  stages  of  its  development.  Segmen- 
tation occurs  precisely  the  same  as  in  the  tertian  variety.  Crescents 
later  make  their  appearance  within  the  blood  corpuscles,  become 
spindle-shaped,  and  eventually  turn  into  spheres. 

Lesions. — The  lesions  in  children  affected  with  malaria  are  practically 
the  same  as  those  in  the  adult.  Chief  among  them  are  destruction 
of  the  red  corpuscles  and  enlargement  of  the  spleen  which,  in  the 
chronic  type,  becomes  hyperplastic  and  pigmented.  Other  organs, 
such  as  the  liver,  kidneys,  and  brain,  may  show  evidences  of  pig- 
mentation, depending  upon  the  duration  of  the  infection. 

Clinical  Forms  of  Malaria. — Intermittent  Forms. — Two  varieties  of 
this  type  are  seen — namely,  the  tertian  and  the  quartan,  the  latter 
being  the  more  common.  Both  are  characterized  by  a  cold  and  hot 
stage.  The  former  begins  with  headache,  lassitude,  and  sometimes  by 
nausea  and  vomiting,  which  are  soon  followed  by  a  chill.  This  may 
be  so  severe  as  to  cause  chattering  of  the  teeth,  shaking  of  the  body. 


MALARIA  735 

and  a  cold,  bluish  appearance  of  the  skin.  The  pulse  becomes  rapid, 
and  there  may  be  an  increased  quantity  of  urine  voided.  At  this  time 
the  skin  surface  may  be  subnormal  in  temperature,  whereas  the 
temperature  by  rectum  or  axilla  is  very  much  elevated. 

This  stage  may  last  from  a  few  minutes  to  a  couple  of  hours,  and  then 
the  hot  stage  sets  in.  The  skin  temperature  becomes  elevated,  the  face 
is  flushed,  the  pulse  full  and  bounding.  This  lasts  from  one  to  several 
hours,  and  is  followed  by  the  sweating  stage,  during  which  perspiration 
appears  all  over  the  skin  surface,  and  results  in  a  profuse  sweat. 
Coincident  with  this  the  headache,  nausea,  and  other  symptoms 
disappear,  and  the  patient,  overcome  by  exhaustion,  sinks  into  sleep. 

Marked  variations  in  the  course  of  the  disease  may  be  observed  in 
very  young  children,  the  different  stages  being  indistinct,  and  the 
disease  assuming  a  remittent  character.  In  very  young  children  cyan- 
osis takes  the  place  of  chills;  there  is  restlessness,  yawning,  nausea, 
twitching  or  convulsions,  coldness  of  the  extremities,  and  sometimes 
diarrhea.  The  hot  stage  is  almost  invariably  accompanied  by  fever 
of  a  higher  degree  than  is  seen  in  adults,  often  reaching  105°  to  106°  F. 

The  child  is  restless  also  in  this  stage;  the  face  is  hot  and  flushed, 
the  eyes  are  injected;  there  is  severe  pain  in  the  head,  back,  and 
limbs,  the  pulse  is  full  and  rapid,  and  the  urine  scanty  and  high- 
colored.  This  stage  usually  lasts  an  hour  or  two,  after  which  the 
pain  and  fever  subside,  and  the  child  breaks  into  a  profuse  sweat. 

The  child  six  years  old  or  more  has  paroxysms  similar  to  those  in  the 
adult,  but  very  often  the  symptoms  in  younger  children  are  so  masked 
that  malaria  is  not  suspected  at  first,  and  a  diagnosis  of  progressive 
anemia  may  be  made  because  of  the  pallor  and  enlarged  spleen.  In 
the  tertian  form  of  malaria,  the  child  may  appear  perfectly  well  in  the 
interval  between  paroxysms. 

The  sweating  stage  is  often  entirely  wanting,  or  may  be  so  slight 
as  to  be  unnoticed.  The  disease  may  make  its  appearance  as  a  remittent 
fever,  and  eventually  becomes  intermittent.  The  quotidian  type  is 
the  form  most  frequently  observed  in  children.  Next  in  frequency 
is  the  tertian  variety,  whereas  the  quartan  form  is  extremely  rare. 
Examination  of  the  spleen  usually  shows  some  degree  of  enlargement, 
and  in  chronic  cases  the  liver  may  be  enlarged. 

-  The  course  of  the  disease  varies  greatly.  Recovery  may  occur 
after  a  few  paroxysms  with  little  or  no  medication.  When  malaria 
persists  for  some  length  of  time,  anemia  and  hematogenous  jaundice 
may  result  from  blood  destruction,  or  the  disease  may  eventually 
become  chronic. 

Irregular  Form. — In  young  children  the  disease  is  apt  to  manifest 
itself  by  merely  vague  symptoms,  instead  of  the  train  of  symptoms 
which  usually  mark  the  onset  in  adults.  Nervous  phenomena  are 
common,  such  as  severe  frontal  headache  accompanied  by  vomiting 
and  lassitude.  Pain  in  any  part  of  the  body,  together  with  some 
tenderness,  may  be  the  first  sign  of  a  paroxysm.  Again,  a  paroxysm 
may  be  ushered  in  with  vomiting,  high  fever,  embarrassed  respiration, 


736  THE  SPECIFIC  INFECTIOUS  DISEASES 

cyanosis,  and  prostration.  Frequently  moist  rales  may  be  heard  over 
the  lungs,  and  cause  the  disease  to  be  mistaken  for  pneumonia. 

Chronic  Forms. — In  many  instances  these  forms  can  be  recognized 
only  by  finding  the  malarial  parasites  in  the  blood.  Anemia,  with 
fever  and  enlargement  of  the  spleen,  is  the  most  constant  symptom. 
The  anemia  is  usually  quite  pronounced,  the  spleen  in  most  instances 
sufficiently  enlarged  to  be  readily  palpated,  while  the  fever  is  often 
so  mild  that  it  is  entirely  unnoticed.  Other  symptoms  of  minor 
importance  which  may  manifest  themselves  are  headache,  occasional 
vomiting,  weakness,  constipation,  muscular  pains,  and  mild  bronchitis. 

When  a  child  has  suffered  from  repeated  attacks  of  malaria,  or  the 
disease  becomes  chronic,  marked  cachexia  may  develop.  The  child 
becomes  emaciated,  there  are  gastro-intestinal  disturbances  with 
anorexia  and  diarrhea,  the  features  are  drawn  and  pinched. 

Pernicious  Malaria. — Pernicious  malaria  is  rarely  seen  in  temperate 
climates;  it  is  characterized  by  extreme  intensification  of  all  the 
symptoms. 

Diagnosis. — This  can  readily  be  made  on  finding  the  parasites  in  the 
blood,  especially  if  the  blood  is  examined  at  the  time  of  a  paroxysm, 
and  quinin  has  not  been  administered.  Often  the  blood  if  taken  from 
the  fingers  will  be  negative,  consequently,  whenever  possible,  it  should 
be  removed  from  the  spleen.  In  view  of  the  fact  that  conditions  are 
not  always  favorable  for  making  a  blood  examination,  either  because 
of  lack  of  experience  or  equipment,  the  therapeutic  test  should  be 
resorted  to,  namely,  the  administration  of  quinin. 

Suspicion  should  always  be  aroused  if,  in  a  given  case,  the  symptoms 
are  more  or  less  periodic  in  nature  and  the  spleen  is  enlarged.  In  the 
chronic  forms  of  the  disease  the  profound  anemia  and  cachexia, 
together  with  muscular  pains,  fever  of  low-grade  type,  and  splenic 
enlargement  ought  to  differentiate  the  disease  from  tuberculosis, 
peritonitis,  meningitis,  lymphangitis,  also  from  empyema,  endo- 
carditis, typhoid  fever,  and  influenza.  Because  of  the  fever  and 
recurrent  chills  which  accompany  pyelitis  this  disease  is  frequently 
confounded  wdth  malaria.  Certain  affections  accompanied  by  enlarge- 
ment of  the  spleen,  such  as  leukemia,  rickets,  and  hereditary  syphilis, 
must  also  be  differentiated.  These  diseases  can  usually  be  excluded  by 
careful  examination,  and  the  diagnosis  of  malaria  confirmed  by  the 
therapeutic  test,  administration  of  quinine,  and  by  examination  of  the 
blood. 

Prognosis. — As  a  rule,  the  prognosis  is  favorable  if  the  child  affected 
by  the  disease  does  not  reside  in  a  malarial  district.  In  a  very  young 
child,  a  severe  attack  of  malaria  may  so  lower  its  power  of  resistance 
as  to  make  it  particularly  susceptible  to  infections  of  other  types. 
As  a  rule  mild  cases  eventuate  in  spontaneous  recovery,  and  in  the 
majority  of  cases  of  malaria  children  recover  promptly  if  the  disease 
is  correctly  diagnosed  and  treated. 

Treatment. — Prophylaxis. — In  view  of  our  knowledge  of  the  mode 
of  transmission  of  the  disease,  not  only  can  its  prevention  be  accom- 


MALARIA        •  737 

plished,  but  the  disease  can  as  well  be  ultimately  exterminated.  All 
houses  in  malarial  districts  should  be  screened  by  mosquito  nets,  and 
all  parts  of  the  body  exposed  to  the  bite  of  the  mosquito  should  be 
bathed  with  lotions,  which  contain  such  drugs  as  menthol,  turpentine, 
or  pennyroyal,  which  are  obnoxious  to  the  mosquito.  Pools  of  water 
should  be  drained,  and  when  this  is  impossible  petroleum  should  be 
sprayed  on  the  surface.  Children  who  have  previously  suffered  from 
the  disease  should  undergo  treatment  each  spring  and  autumn  for  at 
least  four  or  five  years  following  an  initial  attack. 

Prophylaxis  is  most  important,  especially  in  malarious  districts. 
The  child's  sleeping  quarters  should  be  effectively  screened,  and  it 
should  be  protected  from  mosquitoes  in  every  possible  way. 

The  treatment  of  the  disease  is  more  or  less  symptomatic;  in  the 
cold  stage  stimulation,  and  in  the  hot  stage  the  application  of  cold  to 
the  body  in  the  form  of  sponging,  or  an  ice-bag  to  the  head.  Laxatives 
should  be  freely  given  early  in  the  attack. 

Administration  of  Quinine. — Owing  to  the  disagreeable  taste  of  this 
drug  it  is  necessary  to  administer  it  in  such  forms  as  are  willingly  taken, 
and  will  cause  the  least  irritation  to  the  stomach.  The  bisulphate 
of  quinine  seems  to  have  preference  over  other  forms  in  that  it  is  less 
likely  to  upset  the  stomach.  When  given  by  mouth  an  aqueous  solu- 
tion suffices,  a  fluidram  containing  1  or  2  grains  of  the  drug  being 
administered  four  times  daily,  the  last  dose  three  or  four  hours  before 
the  expected  paroxysm.  Older  children  may  be  given  3  to  5  grains  in 
the  same  manner.  The  administration  of  larger  doses  of  quinine,  that 
is,  2  grains  every  two  hours,  is  often  of  advantage,  if  given  for  eight 
hours  preceding  the  paroxysm,  and  1  to  2  grains  three  times  a  day  in 
the  intervals  between  attacks.  Massive  doses  may  be  gradually 
decreased  as  the  symptoms  subside. 

When  quinine  is  given  by  rectum  a  larger  dose  is  necessary,  and  it 
should  be  injected  in  a  starchy  solution  of  some  kind,  such  as  gruel. 
It  may  be  administered  hypodermically  in  the  form  of  the  bimuriate 
with  urea,  bisulphate  or  hydrobromate,  and  the  hydrochlorosulphate. 
Because  of  its  irritating  properties  it  seldom  if  ever  should  be  used 
in  this  manner,  as  it  almost  invariably  causes  a  marked  induration  at 
the  site  of  injection,  and  necrosis  of  the  tissues  may  result.  Especialh' 
is  this  apt  to  be  the  case  when  it  is  administered  in  the  above  manner 
to  very  young  children  or  to  those  whose  resistance  is  lowered. 

In  older  children  the  disagreeable  taste  of  quinine  can  to  a  certain 
extent  be  disguised  by  the  use  of  such  vehicles  as  syrup  of  sarsaparilla, 
syrup  of  orange,  etc.,  or  it  may  be  given  in  chocolate-coated  quinine 
lozenges.  Euquinine  is  easier  to  administer  to  young  children  because 
practically  tasteless.  The  dose  is  the  same  as  that  of  quinine  sulphate. 
In  still  older  children  quinine  may  be  administered  in  the  same  way  as 
to  adults. 

In  order  to  obtain  the  maximum  results,  quinine  should  be  so  admin- 
istered that  a  relatively  large  dose  is  taken  a  few  hours  prior  to  the  time 
of  the  expected  paroxysm.  This,  however,  is  not  always  possible  if 
47 


738  THE  SPECIFIC  INFECTIOUS  DISEASES 

the  stomach  shows  intolerance  of  the  drug.  Children  will  often  be 
found  to  take  relatively  large  quantities  of  quinine,  8  to  10  grains  of  the 
sulphate,  and  10  to  12  grains  of  the  bisulphate  daily,  without  any 
evidence  of  disturbance.  Under  intelligent  treatment  with  quinine,  the 
spleen  will  diminish  in  size,  and  the  paroxysms  disappear. 

Children,  as  stated,  usually  bear  quinine  well,  and  cinchonism  does 
not  occur  as  readily  as  in  adults.  Even  after  the  child  has  apparently 
recovered,  it  is  a  good  prophylactic  measure  to  give  10  to  15  grains 
of  quinine  sulphate  one  day  out  of  each  week  until  the  anemia  has 
disappeared  and  the  spleen  is  no  longer  palpable.  It  should  then 
be  given  periodically  at  longer  intervals.  In  the  chronic  forms  of 
malaria,  Fowler's  solution  and  ferric  chloride,  each  1  to  3  drops, 
should  be  given  in  combination  with  quinine,  and  the  children,  when 
possible,  removed  to  a  different  climate. 

SYPHILIS. 

Syphilis  is  a  communicable  disease  which  results  from  infection  by  a 
specific  microorganism  known  as  the  Spirochseta  pallida  of  Schaudinn. 
The  organism  is  found  in  the  primary  lesion  and  the  inguinal  lymphatic 
glands,  also  in  the  liver,  spleen,  and  cutaneous  lesions  of  congenital 
syphilis. 

In  the  acquired  form  syphilis  is  characterized  by  the  appearance  of  a 
chancre  followed  by  general  lymphatic  involvement,  by  eruption  on 
the  skin  and  the  mucous  membranes,  then  by  infiltration  of  the  body 
tissues,  the  bones,  and  their  covering,  eventually  by  the  formation 
of  gummata,  which  appear  chiefly  in  the  connective  tissue.  Both 
the  acquired  and  hereditary  forms  of  the  disease  are  seen  in  infancy 
and  childhood. 

Acquired  Syphilis. — This  form  of  the  disease  is  occasionally  seen 
in  children,  though  less  commonly  than  the  hereditary  form. 

Modes  of  Infection. — Infection  occurs  in  various  ways,  being  chiefly 
transmitted  by  the  mother,  who  acquires  syphilis  after  the  child's 
birth,  and  conveys  it  to  the  offspring  either  by  nursing,  kissing,  or 
other  form  of  contact.  It  is  possible  for  a  child  to  become  infected 
at  the  time  of  its  birth,  but  this  is  rare,  and  is  due  to  syphilitic  lesions 
upon  the  genitalia  of  the  mother.  Infection  may  also  be  conveyed 
by  wet  nurses  or  by  lesions  upon  the  nipple. 

The  statistics  of  Fournier,  showing  the  source  of  infection  in  a  series 
of  40  cases,  attributed  the  infection  to  parents  in  19,  to  nurses  in  8, 
to  servants  in  4,  to  sexual  contact  in  4,  to  vaccination  in  2,  to  other 
children  in  2,  and  to  the  physician  in  1.    . 

Symptoms. — The  disease  follows  the  same  course  in  children  as  in 
adults.  In  from  three  weeks  to  a  month  after  inoculation,  the  primary 
lesion,  or  chancre,  appears  at  the  site  of  infection,  which  is  usually 
about  the  mouth  or  some  other  part  of  the  face,  rarely  the  genitals. 
This  is  followed  by  the  appearance  of  secondary  symptoms,  chief  of 
which  are  eruptions  upon  the  skin  and  mucous  membranes,  later  by 


SYPHILIS  739 

tertiary  symptoms  which  may  appear  at  any  time  from  three  to 
twenty-five  years  after  the  infection. 

Prognosis. — The  prognosis  in  acquired  syphiHs  is  much  more  favor- 
able than  in  the  hereditary  form,  and  the  course  of  the  disease  is 
usually  mild.  Even  in  infancy,  there  is  no  marked  impairment  of  the 
general  health,  and  the  mortality  is  less  than  10  per  cent,  of  that  in 
hereditary  syphilis. 

Diagnosis. — In  the  acquired  form  the  diagnosis  is  made  by  the 
appearance  of  a  chancre,  by  a  history  of  infection,  and  by  secondary 
manifestations.  In  hereditary  syphilis  there  is  no  primary  lesion.  The 
infant  has  chronic  rhinitis,  and  pemphigus  or  bullse  on  the  palms  and 
soles  which  are  not  observed  in  the  acquired  form.  Hutchinson's 
teeth  are  strongly  suggestive  of  congenital  syphilis. 

Hereditary  Syphilis. — This  form  of  the  disease  is  transmitted  either 
from  the  father  or  from  the  mother  or  from  both  parents.  Transmission 
depends  to  some  extent  upon  the  stage  of  the  disease  in  the  parents 
at  the  time  of  conception,  and  is  more  apt  to  occur  during  the  secondary 
stage.  In  cases  where  the  parents  have  been  infected  prior  to  the  birth 
of  any  of  their  children,  the  first-born  child  is  more  apt  to  be  the 
victim  of  the  disease  than  the  children  born  later. 

Descent  from  the  father,  also  known  as  seminal  transmission,  is  more 
common  than  infection  from  the  mother.  In  such  cases,  and  provided 
no  lesions  exist  along  the  genital  tract,  the  seminal  fluid  will  not  cause 
a  chancre  if  inoculated  into  a  normal  being,  yet  it  carries  with  it  the 
infection  when  fertilizing  the  ovum.  Sometimes,  even  under  such 
circumstances,  an  apparently  healthy  child  may  be  born.  Or  a  father 
who  has  acquired  syphilis,  yet  at  the  time  conception  takes  place  is 
free  from  all  evidence  of  it,  may  beget  a  child  with  a  most  virulent 
form  of  the  disease. 

Descent  from  the  mother  may  occur  in  three  ways: 

1.  Infection  prior  to  conception. 

2.  Infection  at  the  time  of  conception. 

3.  Infection  following  conception. 

When  infection  occurs  at  the  time  of  conception,  the  case  is  one  of 
paternal  heredity,  due  to  the  syphilitic  spermatazoa  of  the  father. 
If  the  mother  alone  has  syphilis,  the  disease  may  be  transmitted,  but 
the  chances  of  transmission  are  much  less  than  when  the  father  alone 
is  infected.  If,  at  the  time  of  conception,  the  mother  is  the  subject  of 
tertiary  symptoms  of  the  disease,  there  is  great  probability  that  the 
child  will  escape. 

Maternal  infection  exerts  a  more  harmful  influence  than  infection 
from  the  father,  because  of  the  dyscrasia  which  already  exists  in  the 
mother,  and  produces  lesions  of  the  placenta  which  interfere  with  the 
maternal  blood  supply,  and  which,  if  these  lesions  involve  a  large 
part  of  the  placenta,  will  usually  cause  an  abortion.  If,  however,  the 
placenta  is  only  in  part  involved,  the  fetus  is  retained  a  longer  period 
in  utero,  and  may  even  be  born  dead  at  full  term,  or  alive  with  the 
evidences  of  syphilis  more  or  less  marked.    Infection  durmg  gestation 


740  THE  SPECIFIC  INFECTIOUS  DISEASES 

can  be  transmitted  to  the  fetus  up  to  the  eighth  month,  after  which 
time  the  chances  of  escape  are  highly  probable. 

Descent  from  both  parents,  also  known  as  mixed  heredity,  is  fairly 
certain  if  both  parents  are  suffering  from  syphilis  at  the  time  of  con- 
ception, and  the  virulence  of  the  disease  is  greater  than  in  hereditary 
disease  of  either  maternal  or  paternal  origm  alone. 

A  healthy  mother  may  give  birth  to  a  syphilitic  child,  this  child 
not  being  capable  of  infecting  its  mother  either  by  nursing  or  other- 
wise, and  the  mother  remaining  apparently  free  from  the  disease ;  yet 
such  a  child  is  capable  of  infecting  a  wet  nurse.  This  is  known  as 
Colic's  law. 

Furthermore,  it  is  possible  for  a  syphilitic  mother  to  giv?  birth 
to  an  apparently  healthy  child,  the  child  in  all  probability  having 
acquired  a  certain  degree  of  immunity  from  the  disease  while  in 
utero,  or  having  merely  a  latent  form  of  the  disease  (Profeta's 
immunity) . 

Lesions. — Skin. — Save  for  their  severity  the  lesions  of  the  skin  are 
practically  the  same  as  those  of  acquired  syphilis.  Depending  upon 
the  time  at  which  they  appear,  they  show  a  certain  degree  of  variation, 
being  most  intense  at  birth,  and  then  usually  either  pustular  or  ulcer- 
ative. When  they  appear  some  weeks  after  birth,  they  are  usually 
erythematous  and  papular  in  type. 

Erythematous  Syphilides. — These  develop  usually  during  the  third 
week  of  fetal  life  as  minute  spots  which  are  of  a  pale  red  color,  some- 
times confluent,  and  which  disappear  upon  pressure.  Usually  they 
are  seen  on  the  face  and  about  the  genitalia,  in  this  way  differing  from 
the  roseola  of  acquired  syphilis.  This  eruption  is  apt  to  be  confused 
with  simple  erythema;  T3ut  the  gradual  transformation  into  papules, 
which  become  scaly  on  the  soles  and  palms,  and  yield  readily  to  anti- 
syphilitic  treatment,  is  a  diagnostic  feature. 

Papular  Syphilides  and  Mucous  Patches. — These  are  more  apt  to 
appear  on  the  face,  palms,  soles,  and  buttocks,  but  may  sometimes 
extend  over  the  entire  body  surface.  The  papules  have  a  tendency  to 
group  and  coalesce,  forming  large  flat  papules.  When  they  occur 
about  the  mouth  they  frequently  develop  into  fssures,  which  bleed 
readily  and  upon  healing  leave  a  scar.  When  situated  upon  warm 
sm-faces,  they  become  denuded  of  their  epithelial  covering,  and  emit 
an  offensive  discharge.  They  are  most  frequently  seen  about  the 
anus  or  mouth.  Papular  syphilides  situated  on  the  palms  of  the 
hands  and  soles  of  the  feet  are  apt  to  show  evidences  of  exfoliation. 
The  fusion  of  a  number  of  such  papules  on  the  surface  of  the  skin  has 
a  tendency  to  make  the  skin  shed  in  large  strips. 

Vesicular  Syphilides. — This  form  is  usually  associated  with  the 
papular  type,  and  appears  as  small  blebs.  Sometimes  the  contents 
of  the  vesicles  become  piuulent,  but  this  occurrence  is  rare,  and 
usually  accompanies  only  the  more  severe  types  of  infection. 

Pustular  Syphilides. — This  type  follows  the  papular  eruption.  In 
some  cases  the  pustules  may  be  seen  at  birth,  in  others  they  may  not 


SYPHILIS 


741 


manifest  themselves  for  a  long  time  after  the  initial  syphilid.  The 
severity  of  the  infection  influences  their  character.  They  usually 
appear  on  the  face,  hands,  soles,  thighs,  scalp,  and  buttocks.  At  times 
the  eruption  may  assume  the  form  of  impetigo,  acne,  or  ecthyma.  As 
a  rule,  the  pustular  eruption  produces  permanent  scars,  and  may 
result  in  extensive  skin  destruction  should  it  be  complicated  by 
cellulitis  and  gangrene. 

Bullous  Syphilides. — This  form,  also  known  as  pemphigus,  generally 
makes  its  appearance  on  the  soles  of  the  feet  and  the  toes,  the  palms 
of  the  hand  and  the  fingers,  and  the  limbs.  The  eruption  consists  of 
blebs  which  are  filled  with  a  clear,  turbid,  or  bloody  fluid,  are  sur- 


FiG.  73. — Inherited  syphilis  in  a  child  two  months  old. 


rounded  by  a  slight  areola  on  a  base  of  reddish  skin,  and  have  a 
tendency  to  coalesce.  The  presence  of  such  an  eruption,  together  with 
lessened  elasticity  of  the  skin  (because  of  a  lack  of  subcutaneous  fat), 
and  a  look  of  old  age,  should  make  one  extremely  suspicious  of  syphilis, 
particularly  if  the  child  is  hoarse  and  has  the  snuffles. 

Tubercular  and  Gummatous  Syjjhilides. — ^These  lesions  may  occur 
at  any  age,  but  more  often  between  puberty  and  the  thirtieth  year.' 
They  may  be  either  ulcerative  or  dry  in  type,  and  usually  appear 
first  upon  the  face  and  the  anterior  surface  of  the  legs  in  the  form  of 
dull  reddish  infiltrations  which  are  painless,  gradually  increase  in  size, 
eventually  ulcerate,  and  become  encrusted.    When  ulceration  does  not 


742  THE  SPECIFIC  INFECTIOUS  DISEASES 

occur,  atrophic  areas  remain,  whereas  cicatrices  which  frequently 
produce  marked  deformities  result  from  the  ulcerative  form. 

Mucous  Membranes. — Coincident  with  the  papular  and  papulo- 
pustular  eruption  on  the  skin  is  the  appearance  of  similar  lesions  upon 
the  mucous  membranes,  which  appear  in  the  form  of  mucous  patches 
in  the  mouth.  The  mucous  membrane  of  the  pharynx,  the  mouth,  the 
larynx,  the  ear,  and  the  nose  are  all  subject  to  this  eruption.  One 
of  the  earliest  and  most  significant  evidences  of  the  disease  is  coryza, 
which  is  manifested  by  a  discharge,  at  first  watery,  which  when  dry 
forms  crusts,  underneath  which  are  minute  ulcers.  This  in  turn  clogs 
the  air  spaces,  causing  difficult  respiration,  and  the  characteristic 
snuffles.  The  hoarseness  which  is  so  typical  is  the  result  of  inflam- 
mation or  even  ulceration  of  the  mucous  surface  of  the  larynx.  When 
there  is  marked  infiltration,  the  air  passages  may  be  so  narrow  as  to 
produce  dyspnea  and  occasionally,  though  rarely,  death. 

Tertiary  lesions  of  the  disease  manifest  themselves  usually  at  or 
about  puberty,  and  are  of  the  same  nature  as  those  seen  in  the  adult. 
Infiltrations  extend  to  various  depths,  and  quickly  break  down,  leav- 
ing marked  degrees  of  ulceration.  Such  ulceration  is  apt  to  be  found 
chiefly  about  the  soft  palate,  the  hard  palate,  the  posterior  pharyngeal 
wall,  and  the  mucous  membrane  of  the  nose,  resulting  in  marked 
deformity. 

Bones. — Bone  changes  which  are  found  in  a  syphilitic  fetus,  whether 
it  be  stillborn  or  dies  after  birth,  show  a  marked  degree  of  uniformity. 
The  long  bones  are  the  ones  chiefly  affected,  and  the  changes  are  found 
at  the  epiphyseal  junction.  In  the  early  stages  of  the  disease  there  is 
proliferation  of  the  cartilage  cells,  followed  by  softening  at  the  epiphy- 
seal junction,  and  resulting  detachment  of  the  epiphyses  from  the  shaft. 
As  the  disease  progresses,  certain  degenerative  changes  occur,  which, 
owing  to  infection  by  pus  organisms,  result  in  the  formation  of  abscesses 
about  the  joint,  or  they  may  extend  to  the  medullary  cavity  and  result 
in  osteomyelitis. 

Liver. — Changes  invariably  occur  in  this  organ.  Usually  there  is  a 
more  or  less  diffuse  interstitial  hepatitis,  which  makes  the  organ 
distinctly  larger. 

Lungs. — Changes  in  these  organs  are  more  apt  to  result  from 
hereditary  than  from  acquired  syphilis.  They  usually  manifest  them- 
selves in  the  form  of  gummata  or  as  a  diffuse  infiltration,  the  latter 
condition  being  known  as  white  pneumonia.  Microscopically  the 
alveoli  are  found  to  be  filled  with  fatty,  degenerated  epithelial  cells. 

Spleen. — ^The  spleen  is  frequently  the  seat  of  a  diffuse  interstitial 
splenitis,  and  often  increases  to  three  or  four  times  its  normal  size. 
When  found  during  the  first  three  months  of  life,  it  is  of  some  diag- 
nostic significance,  especially  if  accompanied  by  other  evidences  of 
the  disease. 

Pancreas. — This  also  becomes  the  seat  of  a  diffuse  interstitial  pan- 
creatitis, but  is  usually  not  accompanied  by  sufficient  symptoms  to 
permit  its  detection. 


SYPHILIS  743 

Kidneys. — These,  too,  may  undergo  interstitial  changes,  and  in  a 
certain  percentage  of  cases  albuminuria  is  present. 

Stomach  and  Intestines. — Ulceration  and  gummatous  infiltration  may 
attack  these  organs,  but  so  rarely  that  such  changes  are  of  little  or  no 
importance. 

Circulatory  System. — Interstitial  myocarditis  and  endarteritis  are 
the  usual  lesions,  and  the  latter,  if  severe,  may  result  in  thrombosis. 

Lymphatic  Glands. — Those  most  frequently  affected  are  the  anterior 
cervical  group,  as  well  as  those  groups  which  are  subject  to  tubercular 
invasion,  though  the  changes  produced  differ  from  tuberculous  involve- 
ment in  that  the  enlargement  is  slow  and  painless,  and  even  though  they 
attain  a  great  size  there  is  no  suppuration. 

Nervous  System:  Brain. — This  organ,  when  involved,  is  usually 
the  seat  of  multiple  and  diffuse  lesions  which  produce  symptoms  of 
varying  nature.  Fortunately  its  involvement  is  not  common  in  chil- 
dren, but  hydrocephalus  is  sometimes  seen  in  the  newborn  who  suffer 
from  syphilis,  and  gummatous  infiltration  may  be  present  at  birth. 
Some  children  manifest  the  disease  by  retarded  development  of  the 
brain;  in  these  cases  speech  is  difficult,  and  there  is  a  varying  degree 
of  weakness  which  causes  a  staggering  gait.  Meningitis,  basilar  in 
type,  may  manifest  itself  and  become  chronic.  Involvement  of  the 
spinal  cord  results  in  paralysis  of  either  the  upper  or  lower  extremities, 
according  to  the  location  of  the  lesion. 

Eye. — Interstitial  keratitis  is  one  of  the  most  constant  lesions  of 
hereditary  syphilis,  and  usually  makes  its  appearance  between  the 
seventh  and  fourteenth  years. 

Ear. — Otitis  media  may  develop  owing  to  extension  of  the  inflam- 
mation from  the  Eustachian  tube.  It  frequently  produces  deafness, 
and  may  involve  the  mastoid  cells. 

Teeth. — The  first  teeth  exhibit  no  peculiarities  of  any  importance, 
save  that  they  soon  decay.  It  is  in  the  second  or  permanent  teeth, 
chiefly  the  upper  central  incisors,  that  we  find  the  characteristic 
evidences  of  syphilis.  The  so-called  Hutchinson's  teeth  have  a  shallow 
crescentic  notch  in  the  cutting  edge.  All  cases  of  hereditary  syphilis 
do  not,  however,  manifest  these  changes;  in  fact,  the  teeth  may  show 
varying  degrees  of  deformity. 

Early  Syphilis. — The  early  diagnosis  of  this  disease  depends  upon 
several  factors,  chief  of  which  is  accurate  information  given  by  the 
parents  of  the  presence  of  syphilis  in  either  parent,  or  a  history  of 
frequent  miscarriages,  abortions,  or  stillbirths,  or  a  history  of  several 
children  having  been  born  apparently  healthy,  but  who  survived 
only  a  short  time.  Such  knowledge  is  of  great  importance.  K  child 
may  show  little  or  no  evidence  of  the  disease,  or  there  may  be  an 
eruption  on  the  body  of  pustules  and  papules,  or  bullae  upon  the  soles 
and  palms.  The  liver  and  spleen  are  usually  greatly  enlarged,  and 
there  may  be  evidences  of  interstitial  pulmonitis  or  white  pneumonia. 
Hydrocephalus  also  may  be  present. 

In  many  cases  the  syphilitic  fetus  is  dead  at  birth,  and  at  postmortem 
the  viscera,  bones,  and  skin  all  exhibit  signs  of  fully  developed  lues. 


744  THE  SPECIFIC  INFECTIOUS  DISEASES 

In  other  instances  the  mf ant  is  born  ahve,  but  is  emaciated,  and  bullae 
develop  on  the  hands  and  feet.  The  bridge  of  the  nose  may  be  markedly 
depressed,  and  there  is  a  persistent  coryza,  termed  snuffles.  Fissures 
and  ulcerations  (rhagades)  appear  about  the  lips  and  anus.  The  liver 
and  spleen  are  enlarged. 

Distm-bances  of  nutrition  soon  arise  despite  careful  feeding,  and 
emaciation  is  progressive.  The  facial  expression  is  that  of  a  little  old 
man.  A  diflFuse  papular  and  papulovesicular  rash  usually  appears 
soon  after  birth,  and  the  skin  of  the  face  may  assume  a  copper  color. 
These  infants  rarely  survive. 

In  instances  where  the  child  at  birth  is  to  all  appearances  healthy, 
the  symptoms  of  the  disease  usually  do  not  manifest  themselves  until 
between  the  third  and  sixth  weeks.  Sometimes  the  first  evidence  is 
progressive  emaciation,  but  usually  coryza  is  the  earliest  symptom, 
and  is  frequently  regarded  as  a  simple  cold.  Coincidently  there  may  be 
hoarseness  of  the  voice,  followed  by  the  appearance  of  an  eruption  of 
papules  and  vesicopapules,  some  of  which  become  pustular,  and  on 
bursting  form  crusts  upon  the  surface  of  the  skin.  IMucous  patches 
and  rhagades  also  develop  in  these  cases,  but  condylomata  are  not  as 
common  as  in  the  early  cases. 

The  skin  on  the  soles  of  the  feet,  palms,  knees,  and  nates  is  diffusely 
indurated,  and  the  scaling  may  resemble  eczema.  Copper-colored 
areas  may  be  seen  on  the  thighs,  and  in  some  cases  spread  all  over  the 
body,  giving  the  skin  a  mottled  appearance.  This  is  especially  notice- 
able on  the  face,  for  these  infants  are  usually  pale  and  anemic,  so  that 
the  copper-colored  patches  form  a  sharp  contrast.  The  liver  and  spleen 
may  or  may  not  be  enlarged.  Pseudoparalyses  may  arise,  and  gastro- 
intestinal disturbances  are  common. 

The  various  joints  of  the  body  are  tender  as  the  result  of  acute 
epiphysitis.  Syphilitic  dactylitis  may  appear  as  early  as  the  fourth 
week,  and  cause  a  fusiform  swelling  of  one  or  more  of  the  phalanges. 
It  consists  of  gummatous  infiltration  of  the  periosteum  and  bone  tissue; 
sometimes  the  overlying  skin  and  soft  tissues  become  involved.  In 
neglected  cases,  necrosis  of  the  epiphysis  and  destruction  of  the  joint 
occurs,  and  may  result  in  fistula  formation.  The  loss  in  weight  is 
steady,  the  child  becomes  marasmic,  and  may  die. 

The  differential  diagnosis  between  sj^^hilitic  and  tuberculous  dac- 
tylitis is  very  difficult ;  but  there  is  usually  more  involvement  of  the 
soft  tissues  in  the  tuberculous  form. 

The  ^Yasse^mann  and  von  Pirquet  reactions  are  valuable  aids, 
and  a  therapeutic  test  may  be  made  by  placing  the  patient  on  anti- 
syphilitic  treatment.  Craniotabes  and  bossing  of  the  skull  are  bony 
changes  which,  if  present,  are  always  strongly  suggestive  of  syphilis. 

The  spirocheta  may  be  found  in  the  blood,  internal  organs,  skin, 
and  the  lesions  in  the  mucous  membrane;  but  it  is  difficult  to  demon- 
strate, and  the  ^Yassermann  reaction  of  the  blood  is  a  much  simpler 
method  of  determining  the  presence  of  lues.  If,  after  the  blood  test, 
there  is  still  doubt,  the  Wassermann  or  Noguchi  reaction  should  be 
done  upon  the  spinal  fluid. 


.    SYPHILIS  745 

Late  Hereditary  Syphilis. — The  disease  may  make  its  appearance 
at  any  time  prior  to  the  age  of  puberty.  It  may  or  msiy  not  be  preceded 
by  early  symptoms  of  congenital  lues.  In  some  cases  the  evidences  of 
syphilis  are  continuous  with  infantile  lues,  the  child  having  always 
presented  some  stigmata  of  the  disease,  such  as  iritis  or  sX'pliilides, 
but  other  children  apparently  enjoy  good  health  with  no  eruptions  or 
other  symptoms  until  late  in  childhood,  when  one  or  more  syphilitic 
manifestations  appear.  In  all  probability,  however,  these  are  cases 
in  which  the  early  symptoms  were  so  mild  as  to  escape  attention. 

The  symptoms  at  this  time  correspond  closely  to  those  of  the  tertiary 
stage  in  the  acquired  form  of  the  disease.  There  are  evidences  of 
arrested  development,  the  complexion  is  of  a  peculiar  leaden  hue,  the 
hair  becomes  brittle,  and  the  nasal  bone  may  be  destroyed,  thus  pro- 
ducing a  flatness  of  the  bridge  of  the  nose.  The  cornea  may  be  hazy 
as  a  result  of  interstitial  keratitis.  The  hard  palate  and  nasal  septum 
may  be  perforated,  the  teeth  may  show  the  characteristic  crescentic 
notches,  particularly  the  upper  central  incisors,  and  scars  may  form 
about  the  lips  and  nose.  Enlargement  around  the  epiphyseal  junction, 
and  deafness,  either  partial  or  complete,  are  characteristic  evidences 
of  the  late  form  of  the  disease. 

Dwarfism  and  infantilism  are  often  caused  by  syphilis,  and  are  due 
to  lack  of  development  of  bone  and  muscle.  At  puberty  there  is  but 
a  scant  growth  of  axillary  and  pubic  hair,  and  the  organs  of  generation 
are  abnormally  small.  The  face  is  characteristic,  with  its  lustreless 
skin,  prominent  forehead,  depressed  bridge  of  the  nose,  and  asymmetric 
skull.  Hutchinson's  teeth  and  interstitial  keratitis  often  complete  the 
picture. 

The  Hutchinson  triad,  i.  e.,  syphilitic  deafness,  interstitial  keratitis, 
and  notched  teeth,  comprise  a  symptom-complex  which,  whenever 
present,  is  conclusive  evidence  of  syphilis.  The  bone  lesions  of  late 
syphilis  consist  of  osteoperiostitis  of  the  long  bones  and  cranium,  also 
dactylitis. 

Prognosis. — In  every  case  this  depends  upon  the  extent  of  the  lesions. 
In  consequence  of  the  changes  due  to  the  infection,  such  children  are 
most  susceptible  to  intercurrent  affections.  The  age  at  which  the 
disease  makes  its  appearance,  and  the  promptness  with  which  treat- 
ment is  instituted  greatly  influence  the  prognosis. 

The  breast-fed  infant  with  syphilis  has  a  far  better  chance  for  life 
than  the  bottle-fed  baby,  but  infant  mortality  due  to  syphilis  is  very 
high.  More  than  one-third  of  syphilitic  infants  are  born  dead,  and  of 
those  born  alive  more  than  one-third  die  before  they  are  six  months 
old.  The  longer  the  interval  between  birth  and  the  first  manifestation 
of  the  disease,  the  better  the  prognosis. 

Treatment. — ^This  should  be  instituted  as  early  as  possible,  partic- 
ularly in  cases  where  there  is  a  history  of  the  disease  in  the  parents, 
or  of  miscarriages,  abortions,  and  stillbirths,  or  if  a  child  exhibits  any 
symptoms  whatsoever  of  the  disease.  Mercury  should  be  administered 
just  as  in  the  acquired  form,  and  may  be  given  either  in  inmictions, 
by  mouth,  or  hypodermically;  in  children  inunctions  are  preferable, 


746  THE  SPECIFIC  INFECTIOUS  DISEASES 

10  to  15  grains  of  mercurial  ointment  being  used  daily.  The  ointment 
should  be  rubbed  in  over  a  different  area  each  day,  in  order  to  prevent 
erythema. 

If  given  by  mouth,  either  the  bichloride  or  calomel  may  be  given, 
of  the  former  J-jj  to  ^V'  ^^^  of  the  latter  yV  to  2V  o^  ^  grain,  three  or 
four  times  daily.  When  there  are  lesions  of^tertiary  nature  the  iodides 
should  be  administered,  either  alone  or  in  combmation  with  mercury. 
In  view  of  the  fact  that  in  children  the  iodides  have  little  tendency  to 
upset  the  stomach,  relatively  large  doses  may  be  administered  with 
little  or  no  derangement  of  digestion;  usually  10  to  20  grains  daily 
are  sufficient. 

The  duration  of  the  treatment  should  be  regulated  almost  entirely 
by  the  symptoms.  It  is  never  advisable  to  continue  it  for  long  periods 
of  time  without  an  intermission.  As  there  is  usually  some  degree  of 
anemia  from  the  vigorous  treatment,  tonics  in  the  form  of  iron,  the 
saccharated  carbonate,  1  or  2  grains,  three  times  a  day,  should  be 
administered.  The  syrupi  ferri  iodidi  may  be  given  in  10-  to  20-drop 
doses.  The  child  should  have  plenty  of  fresh  air,  and  careful  hygiene 
and  hydrotherapeutic  measures  should  be  instituted  to  build  up  the 
general  health. 

The  local  treatment  consists  m  the  dusting  of  powders,  such  as 
bismuth  and  calomel,  upon  the  ulcerated  areas,  and  the  cauterization 
with  nitrate  of  silver  of  the  ulcerations  upon  the  mucous  membranes. 
If  rhinitis  is  severe,  the  nose  should  be  irrigated  daily  with  a  1  to  2000 
solution  of  bichloride,  and  iodoform  ointment  may  be  applied  to  the 
inside  of  the  nares.  The  mouth  also  should  be  washed  daily  with  a 
2  to  5  per  cent,  solution  of  potassium  chlorate  to  prevent  salivation 
while  mercury  is  being  given. 

Salvarsan  offers  a  speedy  check  to  the  active  ravages  of  syphilis, 
and  may  be  given  to  children  in  the  dose  of  ^  grain  for  every  60  kilos 
of  body  weight.  This  treatment  should  be  carried  out  only  by  one 
thoroughly  conversant  with  the  technic,  and  the  patient  should  be 
taken  to  a  hospital.    Mercurical  treatment  should  follow  the  injection. 

^^Tlen  epiphysitis  is  present  the  arm  should  be  put  in  a  splint  with 
the  elbow  bent  at  a  right  angle,  and  the  legs  placed  in  straight  splints 
if  the  lower  extremities  are  involved.  In  these  cases  daily  applications 
of  unguentum  h}'drarg;^Ti  should  be  used  locally  in  addition  to  internal 
medication. 

In  both  infants  and  older  children,  the  nutrition  should  be  carefully 
watched.  An  otherwise  healthy  syphilitic  mother  should  nurse  her 
child;  if  this  is  impossible,  a  syphilitic  wet  nurse  may  be  obtained, 
or  the  child  may  be  given  a  carefully  modified  milk  formula.  The 
diet  of  older  children  should  also  be  regulated. 

Where  the  treatment  has  been  carried  out  continuously  for  a  year, 
and  there  have  been  no  active  symptoms  for  six  months,  the  disease 
may  be  regarded  as  well  under  control.  Intermittent  treatment, 
however,  should  be  kept  up  for  a  year  or  two  more  before  the  case  can 
be  considered  cured.  During  intermittent  treatment  the  child  should 
be  given  antisyphilitic  treatment  for  six  months  of  every  year. 


CHAPTER  XXIII. 
RHEUMATISM. 

ACUTE  ARTICULAR  RHEUMATISM. 

A  DISCUSSION  of  acute  articular,  or  acute  inflammatory,  rheumatism 
covers  but  a  small  part  of  the  study  of  rheumatism,  for  in  children 
of  a  rheumatic  diathesis  the  manifestations  of  the  disease  may  be 
numerous,  varied,  and  peculiar.  Arthritis,  so  typical  of  rheumatism 
in  the  adult,  is  often  but  an  insignificant  feature  or  may  be  wholly 
absent;  but  the  skin  frequently  shows  the  effects  of  the  toxins  of 
rheumatism  by  the  appearance  of  urticaria,  erythema  multiforme, 
erythema  nodosum,  or  purpura. 

The  cardiac  manifestations  of  this  disease  are  by  far  the  most 
serious  and,  unfortunately,  are  by  no  means  uncommon.  They 
include  endocarditis,  myocarditis,  and,  occasionally,  pericarditis. 
The  kidneys  are  less  frequently  afi^ected,  but  nephritis  is  occasionally 
the  sequel  to  an  attack  of  rheumatism.  Chorea  is  the  most  common 
neurosis  associated  with  rheumatism,  the  relation  between  these 
two  diseases  being  so  close  that  chorea  is  now  regarded  as  essentially 
of  rheumatic  origin.  Tonsillitis  of  rheumatic  origin  is  a  well  recog- 
nized clinical  entity;  and,  inversely,  many  cases  of  articular  rheuma- 
tism are  now  believed  to  be  due  to  infection  which  has  its  source  in 
the  tonsils. 

Torticollis  may  also  be  due  to  rheumatism,  especially  when  its 
onset  is  sudden,  and  it  is  ushered  in  by  a  spasm  of  the  cervical  muscles 
caused  by  the  irritation  of  the  rheumatic  toxins.  Other  muscles  of 
the  body  may  be  affected  in  like  manner;  but  rheumatism  is  rarely 
the  diagnosis  in  these  cases,  the  symptoms  being  usually  referred  to 
as  "growing  pains"  when  they  occur  in  the  legs,  or  as  "a  stitch  in 
the  side"  when  the  intercostal  muscles  are  affected. 

Barlow  and  Warner,  in  1881,  described  the  rheumatic  nodule, 
which  is  an  oval,  semitransparent,  fibrous  body  looking  like  a  boiled 
sago  grain.  These  nodules  most  frequently  form  at  the  back  of  the 
elbow  over  the  malleolus,  and  at  the  margin  of  the  patella.  Occasion- 
ally they  may  be  found  on  the  extensor  tendons  of  the  hands,  fingers, 
and  toes,  or  over  the  spinous  processes  of  the  vertebrae.  They  are 
composed  of  fibrin  cells  and  fibrous  tissue,  and  vary  in  size  from  a 
pin's  head  to  a  small  pea,  exceptionally  attaining  the  size  of  an 
almond.  They  usually  appear  in  crops,  and  may  remain  for  months, 
but  generally  disappear  within  a  few  weeks. 

Among  the  rarer  manifestations  of  rheumatism  in  children  may 
be  mentioned  mastitis,  periostitis,  and  peritonitis.  In  many  instances 
these  diverse  signs  of  a  rheumatic  diathesis  are  so  slight  and  transi- 


748  ■  RHEUMATISM 

tory  in  nature  that  their  rheumatic  origin  is  overlooked;  but,  at  one 
time  or  another,  these  children  suffer  from  more  or  less  typical  attacks 
of  acute,  subacute,  or  chronic  articular  rheumatism  and  in  these 
seizures  clearly  defined  symptoms  appear  which  reveal  the  true 
nature  of  previous  vague  symptoms  of  the  disease. 

Etiology. — Heredity  is  regarded  as  one  of  the  most  potent  causes 
of  rheumatism  in  children  as  well  as  in  adults,  and  in  such  cases  the 
family  history  often  reveals  rheumatic  affections  in  older  members 
of  the  family,  as  well  as  in  the  young  brothers  and  sisters  of  the  child. 

Acute  articular  rheumatism  may  appear  in  typical  attacks  at  any 
age  from  infancy  to  adult  life;  but,  until  the  tenth  year,  it  is  usually 
atypical.  Infants  are  rarely  attacked;  it  is  uncommon  between  the 
second  and  fifth  years;  but  in  older  children  it  occurs  more  often,  and 
is  most  frequently  observed  between  the  ages  of  ten  and  twenty. 
Girls  are  more  prone  to  chorea  than  boys,  but  otherwise  there  is  little 
difference  in  the  incidence  of  the  disease  in  the  two  sexes. 

Rheumatism  is  most  prevalent  in  the  spring  of  the  year,  and  is 
also  precipitated  by  exposure  to  cold  and  wet.  It  is  more  common 
in  the  poorer  classes,  a  fact  which  is  probably  explained  by  the  damp 
dwellings,  unsuitable  and  insufficient  food,  and  unhygienic  surround- 
ings which  are  factors  in  its  causation.  One  of  the  most  unfortunate 
features  of  rheumatism  is  the  influence  one  attack  of  the  disease  has 
in  producing  another;  for,  once  a  sufferer  from  rheumatism,  there 
is  always  a  strong  tendency  to  future  attacks. 

Many  cases  follow  attacks  of  tonsillitis,  and  occasionally  rheuma- 
tism accompanies  scarlet  fever  and  influenza.  Several  theories  have 
been  advanced  as  to  the  actual  cause  of  rheumatism;  but  in  recent 
years  the  recognition  of  its  infectious  nature  has  steadily  gained  favor. 
Furthermore,  the  theory  of  its  microbic  origin  has  been  strongly 
supported  by  the  occurrence  of  epidemics,  and  by  the  discovery  of 
a  diplococcus  by  Triboulet,  Wassermann,  Pointen,  and  Payne.  This 
organism  is,  in  all  probability,  the  specific  germ,  since  it  is  capable 
of  producing  various  manifestations  of  rheumatism  when  injected 
into  the  lower  animals. 

At  one  time  a  so-called  nervous  theory  of  rheumatism  was  in  vogue, 
but  this  is  now  largely  discredited.  Its  adherents  contended  that 
rheumatism  was  caused  by  a  disturbance  of  the  nerve  centres  pro- 
duced by  cold,  and  that  a  derangement  of  metabolism  resulted  from 
the  primary  disturbance  of  the  nervous  system.  In  consequence  of 
poor  metabolism,  the  nitrogenous  bodies  were  concentrated  into  uric 
acid  and  deleterious  substances  instead  of  urea. 

Other  observers  have  claimed  that  rheumatism  is  due  to  defective 
assimilation,  whereby  are  formed  certain  acids,  among  which  lactic 
acid  is  held  to  be  largely  responsible  in  the  production  of  the  symptoms 
of  this  disease. 

Pathology. — The  pathological  changes  in  acute  articular  rheumatism 
are  slight  and  not  at  all  characteristic.  The  synovial  membrane  of 
the  affected  joints  is  intensely  hyperemic  and  inflamed,  and  there 


ACUTE  ARTICULAR  RHEUMATISM  749 

is  frequently  an  accompanying  inflammation  of  other  serous  surfaces 
of  the  body.  Within  the  joint  is  an  effusion  of  turbid  fluid  which 
contains  leukocytes  and  flakes  of  fibrin,  and  is  usually  sterile. 

The  periarticular  tissues  are  also  infiltrated  with  this  exudate, 
causing  a  swelling  about  the  joints,  and  there  may  be  an  associated 
inflammatory  condition  of  the  tendon  sheaths.  In  protracted  cases 
the  cartilage  may  become  eroded;  but,  as  a  rule,  there  are  no  perma- 
nent changes  within  the  joint.  Exceptionally  the  exudate  in  the 
joint  cavity  becomes  purulent. 

The  characteristic  changes  in  the  heart  are  due  to  the  effect  of 
bacteria  or  the  toxins  of  rheumatism  on  the  endocardium.  They 
consist  in  a  hyperplasia  of  tissue  which  forms  vegetations  on  the  mitral 
valve  and,  as  a  rule,  prevents  perfect  apposition  of  the  valve  leaflets 
and  complete  closure  of  the  valve. 

There  are  also  pathologic  changes  in  the  myocardium,  pericardium, 
pleura,  and,  rarely,  in  the  peritoneum  and  meninges;  but  these  prac- 
tically amount  to  merely  an-  inflammatory  state,  and  are  nowise 
pathognomonic. 

The  fibrin  elements  of  the  blood  are  increased,  and  fibrinous  clots 
are  found  in  the  heart  and  great  vessels.  In  addition,  there  is  severe 
secondary  anemia  with  a  marked  reduction  in  the  number  of  red 
cells.  Proliferative  periostitis  and  subcutaneous  fibrous  nodular 
deposits  are  among  the  rarer  pathological  findings. 

Symptoms. — ^The  symptoms  of  acute  articular  rheumatism  in  the 
child  differ  greatly  from  its  manifestations  in  the  adult.  The  articular 
symptoms  which  form  so  prominent  a  feature  in  later  life  are  much 
less  distinctive,  and  fewer  joints  are  involved.  The  pain  and  swelling 
in  these  joints  are  usually  slight,  and  there  is  frequently  no  redness. 
In  the  ordinary  case  the  fever  is  never  very  high,  and  is  not  of  extended 
duration. 

The  onset  is  not  acute,  but  is  often  preceded  by  a  few  days  of  malaise, 
with  sore  throat,  anorexia,  abdominal  pain,  and  occasionally  vomiting. 
The  pains  about  the  joints  at  this  time  are  transitory  and  indefinite. 
After  this  there  is  commonly  fever  of  100°  to  101°  F.,  and  the  joint 
becomes  swollen  and  tender;  if  the  ankle,  knee,  or  hip  is  involved, 
the  child  is  unable  to  walk. 

In  mild  cases  there  is  merely  stiffness  in  the  affected  joint,  causing 
the  child  to  limp  if  the  leg  is  attacked.  The  knee-  and  ankle-joints 
are  most  often  involved;  next  in  frequency  are  the  small  bones  of 
the  feet,  the  elbows,  and  wrists.  Muscular  spasm  is  not  uncommon. 
In  some  instances  there  is  extreme  tenderness  about  the  muscles  and 
tendon  sheaths,  the  joint  being  but  little  affected;  this  gives  rise  to 
the  so-called  "growing  pains"  of  children,  which  are  often  of  much 
more  serious  nature  than  is  generally  supposed. 

The  urine  in  these  cases  is  highh'  colored,  concentrated  and 
decreased  in  amount.  The  profuse  acid  sweats  so  characteristic  of 
rheumatic  fever  in  the  adult  are  not  as  frequently  observed  in  young 
children,  the  skin  being  more  often  hot  and  dry.    While  of  mild  tj^e, 


750  RHEUMATISM 

this  atypical  form  of  rheumatism  in  the  child  is  apt  to  run  a  relatively 
longer  course  than  in  the  adult,  many  of  the  cases  being  subacute, 
although  a  chronic  affection  is  rare. 

Owing  to  the  predisposing  influence  of  one  attack  of  rheumatic 
fever  upon  another,  recurrences  are  likely  to  happen  from  time  to 
time  throughout  childhood,  and  even  during  adult  life. 

Rheumatic  Symptovis  in  Older  Children.— The  atypical  type  of 
rheumatic  fever  just  described  is  characteristic  of  most  attacks 
observed  in  children  up  to  the  age  of  eight  years,  after  which  the 
symptoms  of  the  disease  conform  more  or  less  to  the  adult  type. 
The  attack  comes  on  suddenly  with  acute  inflammation  of  one  or 
more  of  the  larger  joints.  Pain  is  agonizing,  and  tenderness  so 
exquisite  that  any  attempt  to  palpate  the  joint  causes  the  child  to 
cry  out  in  anticipation  of  the  pain. 

The  skin  over  the  joint  is  usually  of  a  red  and  dusky  hue,  hot  to 
the  touch,  and  edematous.  The  temperature  ranges  from  102°  to  104° 
F.  on  the  first  day,  but  there  are  marked  variations  in  its  course,  and 
it  finally  declines  to  normal  by  ]ysis.  Sweating  is  profuse,  and  its 
peculiar  acid  odor  is  characteristic.  Sometimes  the  skin  is  hot  and 
dry.  The  bowe!s  are  usually  constipated,  the  tongue  is  dry  and 
coated. 

A  distinguishing  peculiarity  of  the  disease  is  the  order  in  which 
the  joints  are  affected,  the  inflammation  appearing  in  a  fresh  joint, 
or  set  of  joints,  as  it  subsides  in  the  one  originally  affected,  so  that 
the  disease  is  seemingly  transferred  from  one  articulation  to  another. 

Cardiac  symptoms,  while  not  uncommon,  occur  less  frequently  in 
these  cases  than  in  subacute  attacks,  in  which  the  joint  symptoms 
are  mild  and  relatively  unimportant. 

Extra-articidar  Syniftoms. — In  children,  especially,  involvement 
of  the  heart  is  of  such  frequent  occurrence  that  it  can  be  reasonably 
regarded  as  a  sign  or  symptom  of  rheumatic  fever.  Either  the  endo- 
cardium, pericardium,  or  myocardium  may  be  affected,  and  in  severe 
cases  all  three  are  inflamed;  but  endocarditis  is  the  usual  finding. 
In  many  instances  it  follows  an  attack  of  rheumatism  so  mild  that 
it  is  impossible  to  obtain  a  history  of  the  illness  from  the  parent. 

There  are  no  special  symptoms  which  attend  the  onset  of  endo- 
carditis, and  it  is  rarely  fatal  during  its  acute  stage,  but  tends  to 
develop  subacute  or  chronic  lesions  which  incapacitate  or  destroy 
life  months  or  even  years  after  the  rheumatic  attack.  The  mitral 
valve  is  almost  invariably  the  site  of  the  endocardial  lesion;  in  most 
of  the  other  cases  the  aortic  leaflets  show  changes;  occasionally  both 
mitral  and  aortic  valves  are  involved.  This  acute  inflammation  of 
the  endocardium  is  usually  of  simple  verrucose  type,  and  is  indicated 
by  an  apical  blowing  systolic  murmur  and  by  the  reduplication  of 
the  cardiac  second  sound. 

There  may  be,  and  frequently  is,  an  increase  in  the  height  of  the 
fever  when  endocarditis  sets  in,  and  also  a  certain  amount  of  palpi- 
tation, dyspnea,  and  precordial  pain.     Even,  when  there  is  no  endo- 


ACUTE  ARTICULAR  RHEUMATISM  751 

carditis,  the  pulse  is  increased  to  120  or  130  per  minute,  and  is  soft 
and  full;  therefore  in  these  cases,  unless  the  pulse  is  decidedly  irregu- 
lar, tachycardia  is  of  no  diagnostic  value  in  determining  the  presence 
of  a  heart  lesion. 

Pericarditis,  while  not  so  frequent  as  inflammation  of  the  endo- 
cardium, is  not  extremely  rare  in  older  children,  and  may  sometimes 
be  seen  in  association  with  endocarditis.  The  inflammation  is,  as 
a  rule,  of  a  dry  fibrinous  type,  the  effusion  consisting  chiefly  of  organ- 
izable  lymph,  often  in  large  amounts.  This  results  in  numerous 
adhesions  and,  on  account  of  the  tendency  to  recurrence  which  is 
characteristic  of  this  form  of  pericarditis,  the  pericardial  sac  may 
eventually  become  almost  obliterated. 

The  most  important  symptom  is  a  to-and-fro  friction  sound,  which 
is  pathognomonic  of  pericarditis.  A  slight  degree  of  myocarditis 
is  often  present  with  either  endocarditis  or  pericarditis,  but  is  more 
marked  w^hen  there  is  endocarditis. 

Skin  Lesions. — These  are  seen  more  frequently  in  children  than 
in  adults,  and  usually  manifest  themselves  by  the  development  of 
purpura  or  erythema.  The  relation  between  the  various  forms  of 
erythema, — simplex,  urticaria,  nodosum,  multiforme,  and  marginatum, 
— is  not  as  yet  clearly  understood.  Erythema  multiforme  is  the  most 
common  erythematous  lesion  caused  by  rheumatism;  urticaria  is  not 
uncommon,  but  erythema  nodosum  is  rare. 

Owing  to  its  frequent  association  with  rheumatism,  purpura  in 
these  cases  receives  the  name  of  purpura  rheumatica.  But  purpura, 
although  not  uncommon  in  rheumatic  children,  also  accompanies 
other  diseases;  therefore  it  is  probable  that  these  extravasations 
under  the  skin  are  due  to  an  accompanying  infection  rather  than  to 
rheumatism  itself. 

Sudamina  and  miliaria  may  appear  as  the  result  of  overactivity 
of  the  sweat  glands,  and  herpes  also  is  occasionally  observed  in  rheu- 
matic children.  Rheumatic  subcutaneous  nodules,  which  have  already 
been  described,  while  more  common  in  children  than  in  adults,  are 
rarely  seen  in  the  eastern  section  of  the  United  States;  but  when  they 
appear  in  children,  they  may  be  regarded  as  a  positive  sign 
of  rheumatism. 

The  Blood. — Examination  of  the  blood  in  acute  rheumatic  fever 
usually  reveals  a  rapidly  developing  and  severe  secondary  anemia 
with  a  decided  decrease  in  red  cell§  and  moderate  leukocytosis.  Blood 
cultures  are  usually  negative,  butMiplococci  have  been  isolated  from 
the  blood  in  severe  attacks  of  rheumatic  fever. 

Muscular  Symjjtoms. — The  muscular  symptoms  of  rheumatism 
consist  chiefly  of  inflammation  of  the  muscles  and  tendons  about 
the  affected  joints,  and  there  is  usually  considerable  swelling  and 
tenderness  in  these  soft  tissues.  In  protracted  cases  of  rheumatism 
some  degree  of  atrophy  may  follow. 

Tonsillitis. — Sore  throat,  especially  tonsillitis,  often  accompanies 
attacks  of  rheumatism  in  children,  and  sometimes  precedes  the  articu- 


752  RHEUMATISM 

lar  s^inptoms.  Some  rheumatic  children,  however,  who  present  no 
articular  symptoms,  are  also  subject  to  attacks  of  tonsillitis.  Follicular 
inflammation  of  the  tonsils  is  the  common  form  in  these  cases,  although 
there  may  be  a  peritonsillar  abscess. 

The  ordinary  sore  tliroat  associated  with  rheumatism  m  children 
usually  lasts  onh'  three  or  four  days,  but  its  subsidence  has  no  appre- 
ciable effect  upon  the  duration  of  the  articular  or  cardiac  symptoms, 
or   upon  their  severity. 

The  Respiratory  Tract. — As  a  rule,  the  organs  of  respiration  are 
but  slightly  involved,  but  there  may  be  a  moderate  degree  of  bron- 
chitis, and  occasionally  pleurisy.  Pneumonia  is  quite  rare,  and  usually 
assumes  the  lobular  type.  Inflammation  of  the  pleura  in  these  cases 
is  usually  serous,  but  may  be  fibrinous.  The  chief  symptom  of  pleurisy 
is  thoracic  pain.  Friction  fremitus  is  rarely  heard  over  a  large  area 
of  the  chest  wall.  As  a  rule  there  is  no  decided  rise  of  temperature 
with  the  onset  of  pleurisy,  and  but  little  increase  in  the  severity  of  the 
constitutional  symptoms.  The  left  chest  is  most  frequently  affected. 
In  some  mstances  the  pleura  becomes  inflamed  through  extension 
from  the  pericardium. 

Although  few  cases  of  pneumonia  can  be  clearly  demonstrated 
to  be  of  rheumatic  origm,  yet  in  several  instances  a  diplostreptococcus 
has  been  isolated  from  the  sputa  in  pneumonia,  and  also  from  the 
pleural  effusion. 

Nervous  Manifestations. — Chorea  is  the  most  common  nervous 
afi^ection  related  to  rheumatism,  and  may  precede,  accompany, 
or  follow  a  rheumatic  attack.  Sometimes  it  accompanies  endocar- 
ditis, and  there  are  no  articular  s^^nptoms.  ]More  than  one-half  the 
children  who  are  subject  to  chorea  are  of  a  rheumatic  diathesis,  while 
those  who  suffer  frequently  from  rheumatism  are  usually  neurotic. 
Headaches  are  common  among  these  children,  they  are  easily  excited, 
frequently  suffer  from  night  terrors,  and  display  other  evidences  of 
a  nervous  temperament. 

These  nervous  phenomena  are  probably  due  to  three  causes — 
nervous  irritation  and  exhaustion,  high  fever,  and  profound  toxemia. 
In  uncomplicated  cases  of  rheumatic  fever  delhium  is  rare;  but  its 
appearance  may  sometimes  signify  pericarditis,  while  in  others  it 
may  be  due  to  an  overdose  of  the  salicylates.  Convulsions  are  uncom- 
mon, coma  is  rare,  and  meningitis  is  only  exceptionally  a  complication 
of  rheumatism  in  children. 

Diagnosis. — ^Vhen  typical  acute  articular  rheumatism  occurs  in 
children  it  is  usually  easy  of  recognition;  but  smce  cases  are  atypical, 
especially  in  young  children,  and  in  some  there  is  no  appreciable 
joint  lesion,  the  disease  is  quite  often  unsuspected.  In  attempting 
to  arrive  at  a  diagnosis  of  rheumatism,  the  family  and  personal 
history  of  the  child  are  important,  as  well  as  the  articular  manifes- 
tations. Other  signs,  such  as  erythemata,  tendinous  nodules,  growing 
pains,  chorea,  sore  throat,  and  pains  in  the  epigastrium  and  chest, 
must  also  be  analyzed  if  the  disease  is  to  be  recognized  in  its  varied  forms. 


ACUTE  ARTICULAR  RHEUMATISM  753 

An  examination  of  the  heart  in  a  suspicious  case  may  often  reveal 
the  presence  of  endocarditis,  which  is  a  great  aid  to  the  diagnosis 
of  rheumatism  in  those  cases  in  which  there  is  no  joint  involvement. 
The  diagnostic  points  in  a  typical  attack  of  inflammatory  rheumatism 
in  a  child  are  as  follows:  a  history  of  rheumatism  in  the  family  and 
of  repeated  attacks  of  sore  throat;  inflammation  of  one  or  more  of 
the  large  joints  with  a  tendency  to  shift  from  one  joint  to  another; 
and  signs  of  endocarditis. 

In  infancy  rheumatic  arthritis  is  so  rare  that  many  other  conditions 
common  at  this  time  of  life  should  be  considered  before  such  a  diag- 
nosis is  made.  In  infants,  scurvy  is  often  mistaken  for  rheumatism, 
and  the  differentiation  may  be  difficult  until  demonstrated  by  the 
characteristic  state  of  the  gums.  There  is,  however,  but  little  fever 
in  scurvy;  there  is  almost  always  pain  and  swelling  in  the  lower 
extremities,  the  ends  of  the  long  bones  being  involved,  as  a  rule,  rather 
than  the  joints.  Antiscorbutic  treatment  will  demonstrate  the  pres- 
ence of  scurvy  in  a  few  days,  and  serves  in  these  cases  as  a  thera- 
peutic test.  Acute  rheumatism  must  also  be  differentiated  from  scar- 
latinal arthritis;  but  in  the  latter  disease  there  is  a  history  of  scarlet 
fever  symptoms.  Moreover,  as  the  disease  generally  comes  on  in  the 
second  or  third  weelc,  the  child  is  usually  desquamating.  Scarlatinal 
arthritis  shows  a  marked  tendency  to  involve  the  wrists,  while,  as 
a  rule,  in  acute  rheumatism,  the  larger  joints  are  attacked.  True 
rheumatic  arthritis  may  come  on  during  an  attack  of  scarlet  fever, 
and  here  the  diagnosis  is  extremely  difficult. 

Septic  artliritis  occurring  in  the  course  of  pyemia,  and  the  poly- 
arthritis occasionally  observed  just  after  birth,  may  be  confounded 
with  rheumatic  arthritis  in  its  early  stages ;  but,  as  a  rule,  suppuration 
accompanies  these  affections,  and  the  constitutional  symptoms  of 
septic  arthritis  are  much  more  severe  than  those  of  rheumatism. 
In  gonorrheal  arthritis  there  is  usually  a  history  of  vulvovaginitis, 
the  disease  being  most  prevalent  in  girls;  the  knee-joints  are  the 
ones  most  frequently  involved. 

Acute  osteomyelitis  may  produce  symptoms  much  like  those  of 
rheumatism,  and  this  aifection  should  be  excluded  in  every  case, 
its  early  recognition  being  most  important.  The  femur  is  the  most 
common  site  of  osteomyelitis,  it  usually  attacks  only  one  long  bone, 
and  involves  only  one  joint.  Both  the  local  and  constitutional  symp- 
toms are  more  severe  than  those  of  rheumatism. 

Tuberculous  arthritis  may  be  difficult  to  exclude.  It  is  strongly 
suggested  when  there  is  a  slight  attack  of  rheumatism  in  the  hip- 
joint;  but  the  course  of  tuberculous  bone  disease  is  essentially  clironic, 
there  is  less  induration  about  the  joint,  and  the  pain  is  greatest  within 
the  joint. 

Pneumococcal  arthritis  is  acute,  but  is  the  sequel  to  pneumonia, 
and  diplococci  may  be  found  in  the  exudate  within  the  joint.    As  a 
rule  suppuration  sets  in,  and  simplifies  the  differentiation  from  rheu- 
matism, since  the  rheumatic  joint  rarely,  if  ever,  suppurates. 
48 


754  RHEUMATISM 

Epidemic  cerebrospinal  meningitis  with  extreme  and  unusual 
tenderness  of  the  joints  may  suggest  rheumatism;  but,  upon  careful 
study,  the  reflexes  will  be  found  abolished,  there  is  severe  headache, 
and  the  cerebrospmal  fluid  shows  acute  meningeal  inflammation. 

Syphilitic  arthritis  is  usually  monarticular,  but  may  occasionally 
be  mistaken  for  rheumatism;  there  is,  however,  the  usual  history  of 
syphilis  in  mother  and  father  of  the  child;  and,  on  careful  examina- 
tion, concomitant  signs  and  sjTnptoms  may  be  found.  If  necessary, 
a  Wassermann  reaction  will  determine  the  existence  of  lues  in  these 
cases. 

Intra-abdominal  Complications. — These  are  rare,  but  peritonitis 
is  occasionally  seen  together  with  inflammation  of  other  serous 
cavities;  sometimes  these  children  suffer  from  a  nervous  diarrhea 
which  brings  on  defecation  just  before  or  during  a  meal.  Epigastric 
pain  is  a  puzzling  s;yTiiptom  more  or  less  confined  to  children  who 
suffer  from  rheumatism;  it  may  either  be  due  to  a  rheumatic  state 
of  the  abdominal  muscles  or  simply  be  caused  by  an  associated  gastric 
catarrh.  As  a  rule,  there  is  no  tenderness  over  the  epigastrium, 
and  the  pain  usually  disappears  early  in  the  rheumatic  attack.  There 
are  no  gross  lesions  of  any  of  the  abdominal  viscera,  although  the 
spleen  is  often  enlarged. 

Epistaxis  is  not  of  rare  occurrence  m  rheumatic  attacks  during 
childhood,  and  is  rather  an  ominous  sign  because  of  its  association 
with  endocarditis.  Iritis  also  appears  in  some  cases,  owing  to  the 
lodgment  of  rheumatic  organisms  in  the  fine  capillaries  of  the  iris. 

Course  and  Prognosis. — In  children  the  articular  symptoms  of 
rheumatism  usually  subside  within  a  week  or  two;  but  exceptional 
cases  may  be  protracted  for  several  weeks  or  even  months,  while 
in  some  cases  recurrences  are  so  frequent  that  the  children  are  prac- 
ticalh'  never  free  from  rheumatic  manifestations. 

Recovery  from  an  acute  attack  depends  to  a  certain  extent  upon 
the  mode  of  treatment  and  the  promptness  with  which  it  is  instituted; 
but,  if  there  are  no  complications,  the  outlook  is  favorable.  Unfor- 
tunately, however,  children  are  much  more  liable  to  grave  compli- 
cations, such  as  endocarditis  and  pericarditis,  than  adults;  therefore, 
rheumatism  in  childhood  is  a  serious  disease.  With  each  relapse 
fresh  damage  is  done  to  the  heart;  and,  while  cardiac  involvement 
m  an  acute  attack  rarely  proves  fatal,  the  damage  to  the  heart  even- 
tually results  in  death.  The  appearance  of  rheumatic  nodules  is 
regarded  as  a  particularly  unfavorable  sign  in  rheumatism,  since 
they  are  usually  associated  with  cardiac  complications. 

Treatment. — Rest  in  bed  is  the  most  important  and  essential  measure 
in  the  treatment  of  acute  rheumatism  in  children.  By  observing 
this  precaution,  much  can  be  done  to  prevent  the  greatly  dreaded 
cardiac  complications  of  the  disease.  It  is  difficult  to  state  definitely 
how  long  the  child  shall  remain  in  bed,  and  also  hard  to  keep  a  child 
in  bed  after  the  acute  s\Tnptoms  of  rheumatism  have  subsided;  but 
such  grave  consequences  may  follow  if  these  children  play  about  too 


ACUTE  ARTICULAR  RHEUMATISM  755 

soon  that,  to  be  perfectly  safe,  they  should  be  kept  in  bed  for  a  month 
after  an  attack  of  acute  rheumatic  fever.  The  sick-room  should  be 
well  aired,  the  temperature  kept  at  about  70°  F.,  and  all  draughts 
avoided.  The  child  should  wear  a  flannel  night  dress,  and  lie  between 
blankets,  to  prevent  any  chilling  of  the  surface  of  the  body. 

The  diet  should  at  first  be  liquid  but  nourishing,  consisting  for 
the  most  part  of  cereals,  milk,  and  egg  albumen;  later  bread,  vege- 
tables, and  a  little  meat  may  be  given,  but  it  is  wise  to  limit  the 
amount  of  starches.  An  initial  dose  of  calomel,  1  to  2  grains,  should 
be  administered,  and  may  be  followed  by  magnesium  citrate,  2  to  6 
ounces,  or  1  dram  of  magnesium  sulphate,  after  which  the  bowels 
should  be  kept  regular  by  giving,  when  necessary,  smaller  doses  of  the 
citrate  or  sulphate  of  magnesium. 

The  joints  may  be  wrapped  in  a  layer  of  cotton  wool  and  then 
loosely  bandaged.  In  some  cases  the  affected  limb  may  be  more 
effectually  kept  at  rest  by  applying  a  light  wooden  or  cardboard 
splint. 

If  pain  is  severe,  it  is  sometimes  necessary  to  use  a  bed  cradle  to 
keep  the  weight  of  the  bedclothing  off  the  limbs;  in  these  cases, 
particularly,  the  local  application  of  methyl  salicylate,  ichthyol, 
or  of  ice-cold  or  warm  compresses  soaked  in  a  saturated  solution  of 
sodium  bicarbonate  will  often  give  relief. 

For  high  fever  in  rheumatism  a  tepid  sponge  may  be  given,  and 
is  less  harmful  than  antipyretic  drugs.  The  salicylates  are  specific 
in  acute  rheumatic  fever,  and  should  be  given  in  full  dosage,  just 
as  quinin  is  administered  in  malaria;  for,  thus  taken,  they  may  pro- 
tect the  cardiac  valves  and  myocardium  and  pericardium  from  injury 
by  shortening  the  attack  of  the  disease.  From  10  to  20  grains  of 
sodium  or  strontium  salicylate,  according  to  the  age  of  the  child, 
should  be  given  every  three  or  four  hours,  and  it  has  been  demonstrated 
that  if  equally  large  doses  of  sodium  bicarbonate  are  administered 
with  the  salicylates,  the  results  will  be  better  than  if  the  salicylates 
are  used  alone.  When  given  liberally,  the  bicarbonate  of  soda  also 
minimizes  to  some  extent  the  injurious  effects  of  the  salicylates  upon 
the  stomach,  and  aids  in  protecting  the  heart.  If  the  pain  is  not 
relieved  by  the  treatment  outlined,  acetanilid  may  be  given  in  ^-  to 
2-grain  doses  three  times  daily,  or  salol  in  1-  to  3-grain  doses  after 
meals. 

In  the  more  obstinate,  or  subacute  forms,  of  rheumatism  the  salicy- 
lates are  frequently  of  less  value,  and  better  results  are  sometimes 
obtained  by  the  use  of  potassium  iodide,  3  to  5  grains,  three  times  a 
day,  or  the  citrate  or  bicarbonate  of  potassium,  10  grains  every  four 
hours. 

Lemon  and  lime  juice  in  large  quantities  are  very  beneficial.  These 
children  should  be  encouraged  to  drink  water  freely,  especially  Seltzer 
and  Vichy. 

Morphine  should  be  given  only  when  pain  is  severe;  but  some  of 
the  latest  preparations  of  the  salicylates  may  be  used  to  advantage 


756  RHEUMATISM 

in  children;  among  them  aspirin,  dose  3  to  7  grains,  and  novaspirin,- 
5  to  10  grams  three  times  a  day.  These  are  especially  beneficial  when 
the  stomach  becomes  intolerant  to  sodium  or  strontium  salicylate. 
Am.monium  salicylate  may  be  given  in  5-grain  doses  every  three 
hours,  and  sometimes  methyl  salicylate  internally  in  5-  to  10-drop 
doses,  every  three  hours. 

The  heart  should  be  examined  carefully  every  day  for  any  sign  of 
dilatation  of  the  left  ventricle,  for  a  systolic  miumur,  or  imperfec- 
tion in  the  first  sound,  inasmuch  as  the  onset  of  valvulitis  or 
endocarditis  is  not  accompanied  by  any  subjective  or  objective 
symptom. 

When  cardiac  complications  arise  the  child  should  be  kept  as  quiet 
as  possible,  both  mentally  and  physically,  should  use  the  bed-pan, 
and  eat  in  a  recumbent  posture.  If  the  heart  is  overactive,  an  ice- 
bag  may  be  placed  over  it;  if  pericarditis  is  the  cause  of  excessive 
cardiac  action,  tincture  of  aconite  may  be  given  in  \-  to  1-drop  doses 
every  four  hours  until  free  perspiration  is  induced.  If  myocarditis  is 
present  and  the  heart  requires  stimulation,  strychnme  sulphate,  4^ 
to  2-5- 0"  of  a  grain ;  tincture  of  nux  vomica,  1  to  5  drops,  or  ^  to  1  tea- 
spoonful  doses  of  brandy  may  be  given  every  three  hours. 

During  convalescence  children  should  take  general  tonics  and 
receive  special  attention  to  prevent  relapses.  The  anemia  calls  for 
iron,  and  5  drops  of  the  tincture  of  ferric  chloride,  or  5  to  20  drops 
of  the  syrup  of  ferrous  iodide,  may  be  given  after  meals.  Sometimes 
iron  causes  mdigestion  and  bodily  pains,  so  that  it  must  be  discon- 
tinued; and  cod-liver  oil  in  teaspoonful  doses,  quinine  in  1-  to  3-grain 
doses,  or  elixir  of  glycerophosphates  in  teaspoonful  doses,  may  be 
substituted. 

The  diet  should  be  highly  nutritious,  but  care  should  be  taken  not 
to  overfeed,  and  also  to  prevent  constipation.  ]\Iilk,  eggs,  green 
vegetables,  fish,  and  chicken  are  allowable  if  the  digestion  is  good, 
but,  as  a  rule,  it  is  best  to  limit  the  amount  of  red  meats. 

If  no  heart  lesions  are  detected,  the  child  may  be  permitted  to  get 
out  of  bed  two  or  three  weeks  after  the  fever  has  subsided  and  other 
symptoms  have  disappeared..  If  endocarditis  is  present,  rest  in  bed  is 
necessary  for  six  or  eight  weeks  after  it  is  first  noticed.  In  this  case 
the  heart  should  be  carefully  watched  when  the  patient  first  sits  up  in 
bed,  when  he  gets  out  of  bed  to  sit  in  a  chair,  and  when  he  walks; 
on  the  faintest  sign  of  dilatation  or  undue  strain,  rest  in  bed  should 
be  again  resorted  to  until  the  child  can  go  about  and  take  moderate 
exercise  without  apparently  embarrassing  the  heart. 

The  prophylactic  treatment  of  rheumatism  in  children  and  the 
after-care  of  children  who  have  suffered  from  rheumatic  attacks  are 
often  matters  of  great  difficulty.  These  cases  need  a  diet  that  is 
easily  digested  and  is  nourishing,  containing  a  high  protein  content 
and  a  limited  amount  of  starches.  Flannels  should  be  worn  next 
to  the  skin  the  year  round.  If  practicable,  these  children  should  be 
taken  south  for  the  winter  and  spring.     As  a  rule,  the  seashore  air 


MUSCULAR  RHEUMATISM  757 

is  too  damp;  therefore,  unless  there  is  endocarditis,  mountainous 
regions  or  moderate  elevations  provide  the  most  suitable  climate. 
Cold  bathing  is  contraindicated ;  but  a  warm  bath  may  be  given 
each  evening  under  proper  precautions.  When  there  is  an  endocardial 
lesion,  violent  exercise  should  be  forbidden,  games  such  as  foot-ball, 
base-ball,  and  running  races  being  very  harmful.  But  moderate 
exercise  is  necessary,  and  the  child  should  be  encouraged  to  take  short 
walks,  and  may  amuse  itself  with  croquet.  Owing  to  the  frequency 
with  which  rheumatism  follows  tonsillitis,  the  tonsils  should  be  care- 
fully examined,  and  every  case  of  tonsillitis  receive  immediate  and 
efficient  treatment.  Surgical  tonsils  should  be  removed  as  soon  as 
possible. 

MUSCULAR   RHEUMATISM. 

Muscular  rheumatism  is  rare  in  infancy  and  childhood,  but  the 
acute  and  subacute  types  are  occasionally  observed. 

Etiology. — The  exact  cause  of  the  affection  is  unknown,  but  mus- 
cular rheumatism  frequently  follows  exposure  to  cold  or  dampness. 
It  is  claimed  by  some  authorities  that  disturbed  metabolism  exerts 
a  predisposing  effect  upon  this  disease  in  causing  the  liquids  of  the 
body  to  contain  a  large  quantity  of  toxic  materials,  which  are  precipi- 
tated into  the  muscle  structure  by  cold  or  chilling. 

Another  theory  is  that  rheumatism  of  the  muscles  is  caused  by  a 
streptococcus  much  like  the  one  supposed  to  be  the  cause  of  articular 
rheumatism.  x\mong  the  exciting  factors  are  indiscretions  in  diet, 
constipation,  great  physical  strain  or  fatigue,  improper  or  insufficient 
clothing,  and  damp  weather.  One  attack  predisposes  to  another. 
The  disease  is  most  common  in  children  who  are  of  a  rheumatic 
diathesis. 

Pathology. — The  muscle  fibers  are  swollen,  and  on  cross-section 
show  granular  changes.  Under  the  microscope  in  the  acute  form, 
which  is  really  a  myositis,  we  find  round  cell  infiltration  in  the  con- 
nective tissue  and  partial  degeneration  of  the  muscle  fibers. 

Symptoms. — Muscular  pain  and  stiffness  are  the  most  prominent 
symptoms.  Fever  is  rare.  Cardiac  complications  do  not  occur  as 
frequently  as  in  articular  rheumatism.  The  usual  sites  of  muscular 
rheumatism  are  the  cervical  muscles  (torticollis),  the  inter(,'ostal 
muscles  (pleurodynia),  and  the  lumbar  muscles.  As  a  rule,  there 
are  no  constitutional  symptoms. 

Diagnosis. — This  is  usually  easy  to  make,  because  of  the  location 
of  the  pain  and  the  stiffness  in  the  aft'ected  muscles;  but  articular 
rheumatism  and  neuritis  must  always  be  excluded. 

Prognosis. — The  prognosis  as  to  recovery  is  good.  There  is  little 
danger  of  cardiac  complications,  but  recurrences  are  common. 

Treatment. — ^^A^hen  an  attack  of  muscular  rheumatism  follows 
exposure,  the  child  should  have  a  hot  Turkish  bath,  and  then  take 
3  to  6  grains  of  Dover's  powder,  in  three  doses,  one  hour  apart,  and 
be  put  to  bed.    Aspirin,  3  to  7  grains,  salol  2  to  5  grains,  acetanilid, 


758  RHEUMATISM 

gr,  1,  or  phenacetin  in  1  to  2  grain  doses,  may  be  given  three  times  a 
day.  Hot  compresses,  a  hot  iron,  or  a  hot-water  bottle,  placed  over 
the  affected  muscles  will  often  give  relief.  Chloroform  liniment  or  a 
20  per  cent,  salicylic  ointment  may  also  be  applied. 

A  saline  pm-gative,  such  as  1  dram  of  magnesium  sulphate,  or 
20  to  30  grains  of  Rochelle  salts,  should  always  be  given  at  the  onset; 
and,  if  the  urine  is  acid  and  highly  colored,  10  grains  of  sodium  bicar- 
bonate in  a  glass  of  water  may  be  administered  three  times  a  day. 
To  prevent  future  attacks,  these  children  should  be  protected  from 
draughts  and  exposure,  and  should  wear  flannel  or  woolen  under- 
garments the  year  round.  Constipation  should  be  corrected,  and  the 
diet  carefully  regulated. 

CHRONIC   RHEUMATISM. 

Chronic  rheumatism  is  rare  in  children,  but  may  be  the  sequel 
of  repeated  acute  attacks.  It  practically  never  occurs  as  a  primary 
affection,  chronic  arthritic  disease  being  usually  due  to  some  other 
cause,  such  as  syphilis,  tuberculosis,  Still's  disease,  or  rheumatoid 
arthritis. 

Etiology. — Since  most  cases  follow  a  series  of  repeated  attacks  of 
acute  rheumatism,  the  etiology  of  cln-onic  cases  is  essentially  the  same, 
dampness,  exposure  to  cold,  and  heredity  being  the  most  significant 
causes. 

Symptoms. — The  symptoms  are,  for  the  most  part,  referable  to 
the  joints,  which  gradually  become  enlarged,  painful,  and  immobile. 
As  a  rule,  there  are  no  constitutional  symptoms.  The  course  of  the 
disease  is  protracted,  although  relatively  shorter  than  in  adults. 

Diagnosis. — ^Two  diseases,  Still's  disease  and  rheumatoid  arthritis, 
closely  resemble  chronic  rheumatism,  and  in  every  case  should  be 
excluded  when  making  the  diagnosis. 

STILL'S   DISEASE. 

This  affection  is  a  chronic  polyarthritis,  which  usually  appears 
before  the  child  is  five  years  old.  It  is  characterized  by  stiffness 
and  enlargement  of  the  joints,  and  enlargement  of  the  liver,  spleen, 
and  IjTnphatic  nodes. 

Etiology. — The  precise  nature  of  the  exciting  factor  in  this  disease 
is  obscure,  but  it  is  believed  to  be  chronic  sepsis.  Girls  are  affected 
in  greater  numbers  than  boys.  Most  cases  occur  before  the  eruption 
of  the  primary  teeth. 

Symptoms. — Acute  exacerbations  are  accompanied  by  fever  and  by 
tenderness  in  the  affected  joints;  but  the  most  marked  featm-es  of 
the  disease  are  a  gradually  developing  ankylosis  of  the  joints  and 
swelling  due  to  pathological  thickening  of  the  soft  structures.  There 
are  no  exostoses  and  no  degenerative  bone  changes;  but  muscular 
wasting  is  often  extreme.    The  lymphatic  glands  about  the  jomts  and 


RHEUMATOID  ARTHRITIS— ARTHRITIS  DEFORMANS    759 

throughout  the  entire  body  may  be  greatly  enlarged,  the  liver  and 
spleen  hypertrophied,  and  the  blood  picture  is  that  of  severe  anemia. 
Adhesions  of  the  pleiu-a  and  the  pericardium  are  occasionally  observed. 
Prognosis. — Since  there  are  no  destructive  changes  in  the  joints, 
the  prognosis  is  somewhat  more  favorable  than  in  other  chronic 
joint  diseases;  but  complete  recovery  is  rare. 


Fig.  74. — Still's  disease. 


RHEUMATOID    ARTHRITIS--ARTHRITIS    DEFORMANS. 

Rheumatoid  arthritis  is  extremely  rare  in  children,  and  is  at  first 
usually  mistaken  for  clironic  rheumatism.  It  is  marked  by  thickenmg 
of  the  synovial  membrane,  by  enlargement  of  the  articulatmg  surfaces 
of  the  bones,  and,  occasionally,  by  effusions  into  the  joints. 

Etiology. — ^This  disease  is  now  believed  to  be  infectious  in  origin, 
and  the  earlier  theory  that  it  originated  in  the  nervous  system  has 
-^been  largely  discredited.  It  is  usually  the  result  of  exposure  to  damp- 
ness and  cold,  and  the  infection  is  supposed  to  have  its  origin  in 
decayed  teeth,  diseased  tonsils,  or  other  suppurating  foci. 


760 


RHEUMATISM 


Symptoms. — In  exceptional  cases  the  onset  of  rheumatoid  arthritis 
may  be  sudden,  but,  as  a  rule,  it  is  slow.  There  is  usually  no  fever, 
but  the  joints  are  painful  and  swollen,  and  gradually  become  worse. 
When  the  pain  increases,  motion  becomes  limited,  and  in  protracted 
cases  marked  ankylosis  and  muscular  atrophy  occur.  As  the  disease 
progresses,  and  additional  jomts  are  involved,  pain  on  motion  becomes 
more  severe,  and  all  movements  of  the  body  are  restricted.  The 
skin  over  the  affected  joints  has  a  shining,  waxy  appearance,  but 
there  is  no  local  heat,  although  the  body  temperature  may  rise  a 
degree  or  so  at  intervals  during  the  course  of  the  disease. 


Diagnosis. — The  differential  diagnosis  between  the  several  forms  of 
clu-onic  arthritic  disease  is  difficult  at  the  onset,  but  can  usually  be 
made  after  careful  study.  Chronic  rheumatism  is  characterized  by 
stiffness  in  the  joints,  little  or  no  deformity,  and  a  history  of  repeated 
acute  attacks;  while  in  Still's  disease  there  are  both  deformity  of 
the  joints  and  stiffness  due  to  thickening  of  the  soft  structures,  and 
also  glandular  hypertrophy. 

The  chief  diagnostic  feature  of  rheumatoid  arthritis  is  enlargement 


RHEUMATOID  ARTHRITIS— ARTHRITIS  DEFORMANS      761 

of  the  articulating  ends  of  the  long  bones,  which  results  in  ankylosis 
and  marked  muscular  atrophy.  Syphilitic  arthritis  may  simulate 
chronic  muscular  rheumatism;  but  children  with  luetic  changes  in 
the  joints  usually  show  other  symptoms  of  syphilis,  such  as  Hutchin- 
son's .teeth  and  keratitis,  and  in  doubtful  cases  a  Wassermann  should 
be  made  to  clear  the  diagnosis. 

Tuberculous  arthritis  may  be  differentiated  by  the  absence  of 
tuberculous  foci  elsewhere  in  the  body,  the  absence  of  fever  and  of 
a;-ray  findings,  and  by  the  negative  tuberculin  reaction. 


Fig.  76. — Still's  disease.     Same  patient  as  in  Fig.  75,  but  one  year  later. 

Prognosis. — ^The  prognosis  is  good  as  to  life;  but,  as  a  rule,  little 
can  be  done  to  relieve  the  condition  of  the  joints. 

Treatment. — The  treatment  of  chronic  rheumatism  and  of  other 
forms  of  chronic  arthritis  is  much  the  same.  In  the  syphilitic  types, 
antisyphilitic  treatment  is  usually  effective.  Tuberculous  joints 
are  best  treated  by  putting  them  in  a  cast,  but  rest  is  not  indicated 
in  rheumatoid  arthritis,  Still's  disease,  or  chronic  rheumatism,  and 
children  suffering  from  these  diseases  should  be  encouraged  to  use 
the  affected  joints  as  much  as  possible,  stopping  short  of  fatigue. 


762 


MWMAflBM 


Warm  bathing  is  very  beneficial,  and  the  affected  joints  should 
be  massaged  daily.  Ichthyol  is  one  of  the  best  local  applications, 
and  a  25  to  50  per  cent,  ointment  should  be  rubbed  into  the  joint 
twice  daily.  In  certain  cases  baking  or  dry  hot  air  baths  may  be 
followed  by  marked  improvement.  Passive  motion  should  be  prac- 
tised each  day,  and  adhesions  broken  up  while  the  child  is  anesthetized. 


Fig;.  77. — Rheumatoid  arthritis  in  a  girl  aged  twelve  years. 

If  pain  is  severe,  antipyrin  or  phenacetin  may  be  given  in  1  to 
2  grain  doses,  three  times  a  day,  or  potassium  iodide  1  to  5  grains 
at  a  dose  after  meals.  Children  who  improve  under  this  treat- 
ment are  sometimes  enabled  to  walk  by  using  suitable  orthopedic 
appliances. 


CHAPTER  XXIV. 
SCURVY. 

Scurvy,  or  scorbutus,  is  a  constitutional  disease  due  to  prolonged 
malnutrition.  In  about  50  per  cent,  of  the  cases  it  is  associated  with 
rickets,  although  these  two  diseases  are  essentially  distinct.  The 
chief  characteristics  of  scurvy  are  a  tendency  to  hemorrhage  from 
the  gums,  the  nose,  and  other  mucous  membranes,  swelling  and  ecchy- 
moses  about  the  joints,  especially  the  knee  and  ankle,  and  extreme 
tenderness  and  hyperesthesia  of  the  lower  extremities.  There  is 
also  cachexia  and  marked  anemia. 

Scurvy  in  the  infant  is  now  recognized  as  the  same  disease  which 
occurs  in  the  adult,  although  it  is  modified  by  the  different  chemical 
and  biological  conditions  found  in  the  immature  and  rapidly  develop- 
ing organism  of  the  infant  or  child. 

The  faulty  nutrition  which  causes  scorbutus  is,  in  all  probability, 
due  to  the  lack  of  some  food  elements  which  are  essential  to  normal 
metabolic  processes  and  to  growth.  The  exact  nature  of  these  con- 
stituents is  not  clearly  understood,  but  it  is  believed  that  they  belong 
to  the  group  of  vitamines. 

Etiology. — Age  is  one  of  the  chief  etiologic  factors,  most  of  the  cases 
being  observed  in  infants  between  six  and  eighteen  months  of  age. 
Before  the  sixth  month  scurvy  is  rare,  although  Kerley  reports  a  case 
in  an  infant  three  weeks  old.  After  the  second  year  but  few  cases 
occur. 

Infants  of  the  middle  and  upper  classes  are  most  liable  to  this 
disease,  and  the  great  majority  of  cases  have  been  observed  in  private 
practice;  this  offers  a  strong  contrast  to  rickets,  which  is  essentially 
a  disease  of  the  poorer  classes.  Hygienic  surroundings  have  no  influ- 
ence on  the  development  of  scurvy,  and  there  has  been  a  history  of 
previous  gastro-intestinal  derangement  in  such  a  small 'percentage  of 
cases  that  the  state  of  the  alimentary  tract  seems  to  bear  no  relation 
to  this  disease. 

The  theory  that  it  is  of  microbic  origin  is  not  supported  by  the 
clinical  and  pathological  findings.  It  has  apparently  been  proven 
that  the  most  important  etiological  factor  in  the  production  of  sciu-vy 
is  some  error  in  diet;  but  so  far  no  single  dietetic  error  has  been  demon- 
strated as  the  sole  cause  of  this  disease.  Temporary  faulty  nutrition 
will  not  cause  scurvy;  but  the  malnutrition  must  be  prolonged,  and 
investigations  seem  to  indicate  that  this  dietetic  error  is  a  lack  of 
some  essential  food  element,  rather  than  the  presence  of  some  abnormal 
food  constituent. 


764  SCURVY 

In  common  with  most,  other  diseases  of  infancy,  scurvy  appears 
most  frequently  in  bottle-fed  infants,  although  it  does  occasionally 
occur  in  the  breast-fed.  The  cases  in  breast-fed  babies  and  in  those 
fed  on  raw  cow's  milk  form  a  very  small  percentage  of  the  total  number 
of  cases  of  scurvy  which  have  been  studied,  and  some  investigators 
believe  that  in  these  instances  the  milk  which  the  infants  had  received 
had  undergone  some  unexplainable   chemical  or  biological  change. 

It  is  maintained  that  heating  the  milk  removes  from  it  something 
which  is  necessary  for  the  prevention  of  scurvy,  because  of  the  great 
number  of  scorbutic  children  that  have  been  fed  on  pastem-ized, 
sterilized,  or  condensed  milk,  in  comparison  with  the  few  cases  of 
scurvy  which  develop  in  babies  who  are  given  raw  milk. 

In  further  support  of  the  view  that  foods  which  are  heated  tend 
to  produce  scur\'y",  it  has  been  demonstrated  that  many  more  cases 
of  scurvA^  occur  in  children  who  are  given  sterilized  milk  than  w^hen 
pasteurized  milk  is  used,  and  that  when  raw  milk  is  substituted  for 
sterilized  milk  many  of  these  cases  recover  without  further  treatment. 

The  cooking,  or  heatmg,  of  an  mf ant's  food  apparently  destroys, 
changes  chemically,  or  renders  less  digestible  and  assimilable,  some 
principle  of  freshness  within  it,  and  results  in  metabolic  disturbances 
which  cause  scurvy.  By  far  the  majority  of  cases  occur  when  pro- 
prietary foods  are  given  for  a  prolonged  period,  whether  they  are 
prepared  with  or  without  milk. 

From  these  facts  it  is  evident  that  the  heating  or  cooking  of  food 
given  to  infants  is  of  more  importance  in  the  production  of  scurvy 
than  the  use  of,  or  faihne  to  give  any  one  particular  food.  The  fact 
that  scurvy  sometimes  develops  in  breast-fed  babies  and  in  those 
fed  on  raw  cow's  milk  would  appear  to  contradict  the  theory  that 
the  cooking  or  heating  of  the  food  is  responsible  for  this  disease. 

Plantanza's  observations  show  that  although  scurvy  develops 
more  frequently  in  babies  fed  on  heated  milk  which  is  not  used  at 
once  than  on  raw  milk,  yet  the  disease  does  not  develop  when  fresh 
milk  is  heated  and  used  immediately.  Experiments  on  animals  with 
raw  and  heated  milk  have  failed  to  throw  any  light  on  this  phase  of 
the  subject,  for  they  have  been  too  few  to  be  conclusive. 

The  report  of  the  American  Pediatric  Society's  Collective  Investi- 
gation of  Infantile  Scurvy,  in  1898,  brought  out  some  important 
data  with  regard  to  the  preceding  diet  in  379  of  the  cases.  The 
summary  of  this  report  is  given  below. 

Breast  milk,  in  12  cases,  exclusively  in  10. 
Raw  cow's  milk,  in  5  cases,  exclusively  in  4. 
Pasteurized  milk,  in  20  cases,  exclusively  in  16. 
Condensed  milk,  in  60  cases,  exclusively  in  32. 
Sterilized  milk,  in  107  cases,  exclusively  in  68. 
Proprietary  infant  foods,  in  214  cases. 

Morbid  Anatomy. — The  pathological  changes  in  scurvy  are  most 
marked  in  the  bones,  the  bloodvessels,  and  the  blood.  Hemorrhages 
may  be  widespread  and    multiple,  takmg  place  in  the  skin,  mucous 


SYMPTOMS  765 

membranes,  serous  membranes,  internal  organs,  bone-marrow,  and 
between  the  muscles.  The  subperiosteal  hemorrhages  are  the  most 
striking  lesion,  and  may  be  very  extensive. 

The  periosteum  of  the  long  bones  is  thickened  and  congested,  and 
in  some  cases  the  hemorrhages  break  through  the  periosteum  into 
the  surrounding  tissues,  often  infiltrating  the  cellular  structures  about 
the  joints,  although  the  joints  themselves  usually  remain  unaffected. 
These  hemorrhages  are  much  more  common  in  the  lower  than  in 
the  upper  extremities,  and  may  appear  in  any  area  from  the  great 
trochanter  to  the  knee,  or  from  the  knee  to  the  ankle. 

In  the  bone  itself  a  rarefaction  occurs  which  may  or  may  not  be 
due  to  intra-osseous  extravasations.  The  diaphyses  and  epiphyses 
of  these  bones  may  separate,  causing  great  deformity,  although  this 
usually  occurs  in  fatal  cases.  The  lower  end  of  the  femur  or  tibia  is 
most  frequently  affected.  The  minute  changes  which  take  place  in 
the  bones  are  much  like  those  seen  in  rickets,  but  these  changes  are 
probably  a  result  of  the  accompanying  rickets  rather  than  lesions  of 
scurvy. 

Hemorrhages  from  the  gums  are  very  common  in  infants  whose 
teeth  have  erupted,  and  the  gums  have  a  spongy  appearance.  The 
changes  in  the  viscera  are  not  constant,  but  there  may  be  hemorrhages 
in  the  pleura,  pericardium,  and  peritoneum.  Bronchopneumonia 
and  nephritis  have  been  observed  in  quite  a  number  of  cases.  Hema- 
turia without  inflammatory  conditions  in  the  kidneys  is  common, 
and  hemorrhages  may  take  place  in  the  orbit  or  under  the  dura. 

The  alterations  in  the  bloodvessel  walls  are,  as  yet,  not  under- 
stood; but  since  it  has  been  shown  by  the  capillary  resistance  test 
that  there  is  a  weakness  of  the  vessel  walls  in  scurvy,  and  studies 
of  the  blood  have  demonstrated  that  there  is  no  deficiency  of  thrombin 
or  blood  platelets,  and  no  excess  of  antithrombin,  it  is  believed  that 
the  hemorrhages  of  scm-vy  are  due  to  this  alteration  in  the  blood- 
vessel walls. 

Symptoms. — ^There  are  no  characteristic  prodromal  symptoms  in 
scurvy,  although  a  period  marked  by  failing  nutrition,  irritability, 
and  pallor  may  precede  the  first  characteristic  symptom,  which  is 
usually  tenderness  of  the  legs.  Occasionally  other  parts  of  the  body 
are  hypersensitive;  but  in  the  majority  of  cases  tenderness  is  first 
noticed  in  the  leg,  and  this  may  be  so  slight  that,  although  the  infant 
cries  out  now  and  then  M^hen  it  is  handled,  it  is  quiet  when  in  its  bed. 

This  hypersensitiveness  is  often  first  noticed  when  the  infant  is 
being  bathed  or  when  the  mother  or  nurse  is  changing  its  napkin; 
at  the  same  time  it  may  be  observed  that  the  child  holds  one  or  both 
legs  still,  but  moves  its  arms.  At  first  this  tenderness  is  hard  to 
locate,  but  it  subsequently  becomes  constant  and  acute  in  one  or 
more  particular  regions,  usually  about  the  knees  and  ankles,  which 
are  often  swollen,  these  swellings  being  fusiform  in  shape,  and  due 
to  subperiosteal  hemorrhage. 

In  severe  cases  the  tenderness  becomes  excessive,  and  mav  involve 


766 


SCURVY 


all  of  the  extremities,  the  affected  limbs  being  rotated  outwardly  and 
maintained  in  that  position,  producing  the  pseudoparalysis  of  scurvy, 
which  is  caused  by  either  the  reflex  or  voluntary  tenseness  of  the 
muscles.  In  severe  cases  the  disability  to  move  may  be  due  to 
epiphyseal  separation. 

When  the  disease  is  marked,  the  sternum  may  become  separated 
from  the  ribs  and  sink  backward.  The  ecchymosis  about  the  large 
joints  and  the  fact  that  the  child  cries  when  touched,  even  when 
lying  in  its  bed,  often  lead  to  the  belief  that  it  is  injured.  In  advanced 
cases  the  infant  becomes  pitifully  helpless,  and  lies  perfectly  motion- 
less, screaming  with  apprehension  whenever  anyone  approaches  the 
crib,  for  fear  it  may  be  moved. 


Fig.  78. — Scorbutus;  same  child  as  shown  in  a; -ray  plate. 


While  ecchymoses  in  the  skin  are  not  common,  there  are  usually 
changes  in  the  gums  and  mouth  from  the  beginning  of  the  disease. 
The  gums  become  swollen  and  purple,  and  may  almost  cover  the 
teeth,  particularly  the  upper  incisors.  They  bleed  when  touched, 
and  hemorrhages  may  be  spontaneous.  Bleeding  sometimes  takes 
place  in  the  vault  of  the  pharynx  and  conjunctiva,  and  blood  is  fre- 
quently vomited  or  passed  in  the  urine  and  feces.  The  stools  are 
rarely  normal  in  severe  cases,  for  there  is  usually  catarrhal  colitis. 

These  symptoms  all  come  on  gradually  with  irregular  intervals 


PLATE    IV 


X-ray  Plate  of  Child  Sho^^^n  in  Fig.  78. 

1  and  2  show  subperiosteal  hemorrhages  and  slight  ealeifieation  of 
periosteuni  ;  8,  expanded  ends  of  diaphyses  ;  4,  praetieally  normal 
epiphyses. 


TREATMENT  767 

of  apparent  improvement,  and  no  change  in  the  child's  general 
health  may  be  noted  for  several  weeks;  but,  sooner  or  later,  evidences 
of  malnutrition  and  anemia  appear,  and  it  becomes  cachectic  and 
emaciated. 

In  advanced  cases  there  is  usually  irregular  and  inconstant  fever, 
often  due  to  complications;  and,  unless  treatment  is  instituted,  all 
of  the  symptoms  grow  steadily  worse  and  the  case  terminates  fatally 
in  from  two  to  four  months*  by  general  asthenia,  or  some  intercurrent 
infection  or  complication. 

Diagnosis. — ^The  diagnosis  of  scurvy  can  readily  be  made. by  those 
who  have  previously  seen  cases  of  the  disease,  and  once  it  is  suspected 
and  its  cardinal  features  looked  for,  there  is  but  little  trouble  in  recog- 
nizing it. 

The  history  of  an  infant  crying  on  being  taken  up,  and  a  history 
of  such  feeding  as  might  lead  to  the  development  of  scurvy,  together 
with  such  symptoms  as  spongy,  swollen,  bleeding  gums,  soreness 
and  tenderness  of  the  legs,  and  swelling  about  the  large  joints,  should 
leave  no  doubt  in  the  physician's  mmd  as  to  the  nature  of  the  ailment. 
Further  proof  can  be  obtained  by  immediately  placing  the  child  upon 
an  antiscorbutic  diet. 

Rheumatism  is  the  disease  most  frequently  simulated  by  cases  of 
scurvy;  but  rheumatism  is  rare  at  the  age  when  scurvy  is  most  com- 
mon, in  scurvy  there  is  no  fever,  and  the  pain  is  usually  confined  to 
the  legs. 

Poliomyelitis  is  sometimes  suspected  because  of  the  pseudoparalysis; 
but  acute  pains  in  the  limbs  are  rare,  and  there  are  no  local  inflam- 
matory changes  in  poliomyelitis,  while  knee-jerks  are  absent  in  polio- 
myelitis, and  present  in  scurvy. 

Among  the  various  other  diseases  with  which  scurvy  is  occasiorally 
confounded  are  joint  diseases,  malignancy  of  the  bones,  spinal  caries, 
trauma,  and  syphilis  of  the  bone;  but  a  carefully  taken  history  and 
thorough  examination,  followed  by  the  administration  of  orange 
juice  as  a  therapeutic  test,  will,  as  a  rule,  differentiate  between  these 
conditions. 

Prognosis. — This  is  excellent  when  the  disease  is  recognized  early 
and  promptly  treated.  In  most  cases  improvement  is  noticeable 
in  from  five  to  ten  days,  and  complete  recovery  follows  within  two 
to  three  weeks.  In  neglected  cases  the  prognosis  depends  upon  the 
extent  of  the  pathologic  changes,  the  degree  of  malnutrition,  the  age 
of  the  infant,  and  the  presence  or  absence  of  complications.  Relapses 
are  rare  unless  there  is  serious  disturbance  of  the  gastro-intestinal 
tract. 

Treatment. — The  prophylactic  treatment  consists  in  avoiding  the 
continued  use  of  any  food  which  may  have  a  tendency  to  produce 
scurvy,  and  whenever  it  is  necessary  to  use  such  foods  to  supplement 
them  by  giving  a  certain  amount  of  orange  juice  at  stated  intervals. 
When  scurvy  appears,  fresh  cow's  milk  should  immediately  be  substi- 


768  SCURVY 

tilted  for  whatever  food  is  being  given,  the  physician  prescribing  a 
formula  or  milk  mixture  exactly  suited  to  that  particular  infant. 

This  procedure  alone  will  often  cure  the  disease;  but  since  the 
child  usually  suffers  a  great  deal,  fresh  fruit  juice,  which  is  specific 
for  scurvy,  should  be  given  at  once.  Orange  juice  usually  agrees 
with  an  infant  better  than  any  other  fruit  juice,  and  from  one  to  four 
ounces  may  be  taken  daily.  A  teaspoonful,  slightly  sweetened,  may 
be  given,  if  necessary,  every  two  hours,  preferably  an  hour  or  so 
before  each  feeding.  Fresh  beef  juice  and  potato  juice,  as  well  as 
the  juice  of  fresh  vegetables,  are  also  very  beneficial  especially  for 
older  children. 

The  s\Tup  of  the  iodide  of  iron  in  5-  to  20-drop  doses,  and  cod- 
liver  oil  I  to  1  dram,,  three  times  a  day,  are  also  beneficial  when 
anemia  and  malnutrition  are  marked. 

Scorbutic  babies  are  very  susceptible  to  intercurrent  infections, 
and  should  be  protected  against  exposure.  They  should  be  handled 
very  little,  and,  if  epiphyseal  separation  has  taken  place,  splmts 
should  be  temporarily  applied. 


CHAPTER  XXV. 
THE  NERVOUS  SYSTEM. 

I.  INTRODUCTION. 

The  central  nervous  sytem  of  the  newborn  is  the  most  immature 
of  all  the  organs  of  the  body.  This  is  true  not  only  in  regard  to  its 
morphology,  but  its  function  as  well.  The  brain  at  birth  is  relatively 
large,  yet  its  histological  structures  are  poorly  developed,  and  before 
it  can  functionate  as  in  the  adult  substantial  developmental  changes 
are  necessary. 

Morphology. — Brain. — The  brain  at  birth  is  relatively  large  and 
weighs  approximately  one-fourth  of  its  ultimate  weight.  According 
to  Ziehen,  the  weight  of  the  brain  at  birth  in  proportion  to  the  total 
weight  of  the  body  is  1 :8  or  1 : 7,  whereas  in  the  adult  it  is  1 :42  in  the 
male,  and  1:40  in  the  female. 

According  to  Marchand,  the  brain  weighs  at  birth  13  oz.  (371  Gm.) 
in  the  male,  and  12f  oz.  (361  Gm.)  in  the  female.  It  increases 
very  rapidly  in  size  and,  according  to  Pfister  and  Marchand,  the 
original  weight  is  doubled  by  the  ninth  month,  and  trebled  before 
the  end  of  the  third  year.  Its  ultimate  weight  is  reached  between 
the  nineteenth  and  twentieth  years  in  the  male,  and  sixteenth  and 
eighteenth  in  the  female. 

Spinal  Cord. — The  average  weight  of  the  spinal  cord  of  the  new- 
born varies  between  yV  to  yV  of  an  ounce  (3  to  3.4  Gm.)  (Pfister), 
yy  to  I  of  an  ounce  (2  to  6  Gm.)  (Mies).  Like  the  brain,  its  weight 
increases  rapidly,  is  doubled  by  the  fifth  month,  trebled  by  the  end 
of  the  first  year,  and  quadrupled  by  the  beginning  of  the  third  year. 
At  birth  it  is  SyV  inches  (14  cm.)  long,  and  very  slowly  reaches  its 
ultimate  length  of  17  to  17f  inches  (43  to  45  cm.)"  (Pfister). 

Histological  Structure. — The  central  nervous  system  of  the  newborn 
is  composed  of  immature  embryonal  tissue  and  cells  which,  by  further 
growth  and  proliferation,  develop  into  specific  ganglionic  cells  and 
nerve  fibers  invested  with  myelin  and  neuroglia  tissue.  The  most 
marked  structural  change  is  the  investment  of  the  nerve  fibers  with 
myelin. 

According  to  Peritz,  the  most  important  centres  necessary  for  the 
postembryonal  life  of  the  infant  are  first  developed;  namely,  the 
gastro-intestinal  and  cardiorespiratory  centres;  next  those  which 
act  as  a  defence  to  the  body,  primarily  the  sympathetic  system  and 
the  spinal  and  cranial  ganglia,  i^t  the  same  time  are  developed  the 
centres  for  reflex  and  automatic  instinctive  movements  (kicking, 
swallowing,  sucking).  The  development  of  the  sense  centres  follows 
later,  then  the  speech  centre  and,  finally,  the  higher  psychical  centres. 
49 


770  THE  NERVOUS  SYSTEM 

According  to  Tliiemich,  the  myelinization  of  the  tracts  of  the  cord 
at  birth  is  almost  complete  except  that  of  the  pyramidal  tracts;  in 
the  brain  stem  and  cerebellum  numerous  tracts  are  invested  with 
myelin,  whereas  in  the  cerebral  hemispheres  but  few  tracts  and  centres 
have  become  myelinized.  Pfister,  IMonakow,  and  others  have  demon- 
strated at  birth  some  myelmized  fibrse  proprise  and  medium-sized 
association  fibers  in  the  sense  areas  and  tracts,  in  those  for  general 
sensibility,  for  the  tactile,  muscle,  olfactory,  and  visual  senses,  as 
well  as  in  the  motor  zone,  in  the  pyramidal  tracts,  and  certain  seg- 
ments of  the  corona  radiata. 

^Myelinization  progresses  so  rapidly  that  by  the  third  or  fourth 
weeks  the  long  association  fibers  of  the  regio  Rolando  and  regio 
calcarma  are  for  the  most  part  provided  with  myelin.  By  the  end 
of  the  third  month,  most  of  the  sense  areas  have  been  developed,  and 
at  the  end  of  the  first  year  the  majority  of  the  association  fibers  have 
been  almost  completely  invested  with  myelm,  whereas  many  years 
must  pass  before  the  tangential  and  the  subcortical  association  tracts 
reach  their  full  development. 

Peripheral  Nerves. — The  myelinization  of  the  peripheral  nerves, 
according  to  Thiemich,  has  progressed  but  little  at  birth,  and  the 
areas  developed  show  marked  irregularities,  being  interrupted  by 
areas  which  have  not  been  myelinized.  The  development,  however, 
progresses  rapidly,  and  is  complete  by  the  end  of  the  first  year. 

Physiological  Development. — From  what  has  been  stated  of  the 
morphology  of  the  central  nervous  system,  it  may  be  supposed  that 
its  functions  likewise  are  most  immature  at  birth,  and  only  very  slowly 
developed.  This  imperfect  development  is  demonstrated  by  the 
electrical  examination  of  the  central  and  peripheral  nervous  system. 
The  motor  cortex,  sensory,  and  motor  peripheral  nerves  are  so  slightly 
irritable  in  the  first  few  months  of  life  that  the  infant's  face  is  totally 
insensitive  to  strong  electrical  stimuli.  Imperfect  development  on 
the  part  of  the  nervous  system  is  accompanied  by  a  greater  need  of 
sleep,  about  20  hours  daily  being  required  during  the  first  few  weeks, 
and  13  to  15  hours  by  the  end  of  the  first  year. 

The  development  of  the  nervous  system,  however,  is  best  showm  by 
examming  the  reflexes.  The  tendon  reflexes  are  present  at  birth, 
and  are  exaggerated  from  the  second  month  to  the  second  year.  The 
superficial  abdominal  refiex  is  frequently  absent  at  birth,  but  becomes 
very  active  m  older  mfants.  The  Babmski  and  Oppenheim  reflexes  are 
present  normally  up  to  the  sixth  or  even  to  the  tenth  month.  The 
winking  (optic)  reflex  appears  from  the  sixth  to  the  eighth  week,  whereas 
the  conjunctival  and  reflex  closure  of  the  eyelids  exist  at  birth  and 
are  active  dm-ing  the  first  few  months.  The  pupillary  light  reflex 
is  present  at  birth,  and  becomes  especially  active  in  the  latter  part 
of  mfancy.  A  reaction  to  accommodation  has  been  observed  by 
Pfister  after  the  fourth  week.  The  aversion  to  light  disappears  between 
the  tenth  and  twentieth  days. 


INTRODUCTION  771 

Psychological  Development. — Little  is  definitely  known  in  regard 
to  the  psychical  development  of  the  child  at  birth.  Stern  thinks 
that,  considering  the  number  of  tracts  partially  developed  at  birth, 
the  child  possesses  a  primitive  consciousness,  but  that  essentially 
the  child  is  a  subcortical  being.  Its  acts  are  reflex  movements  brought 
about  by  stimuli,  either  from  within  or  without,  the  centres  for  which 
are  located  wdthin  the  cord  and  medulla.  Thus,  the  various  forms 
of  the  more  vulgar  type  of  sensations,  such  as  thirst,  hunger,  and 
pain,  call  forth  instinctively  certain  reflex  responses,  such  as  crying, 
sucking,  kicking  and  swallowing,  which  are  the  protective  vital  mani- 
festations of  the  newborn. 

Sensibility. — In  the  first  few  days  all  sensory  areas  functionate 
sufficiently  to  call  forth  motor  responses.  The  senses  of  touch,  smell, 
and  taste  are  all  developed  at  birth;  whereas  the  two  higher  senses, 
sight  and  hearing,  are  less  highly  developed.  Sight  is  present  in 
its  most  primitive  form.  The  child  reacts  to  the  most  extreme  bright- 
ness, but  has  no  conception  of  color,  form,  position,  or  distance.  At 
about  the  third  or  fourth  day  it  will  momentarily  follow  a  bright  light, 
but  will  not  fix  its  eyes  distinctly  upon  objects  before  the  fourth  or 
fifth  week,  and  not  before  the  third  or  fourth  month  will  the  child 
follow  objects,  and  begin  to  store  up  visual  memories  of  what  it  sees. 

Many  infants  are  deaf  at  birth;  stimuli,  however,  will  call  forth 
responses.  The  child  may  respond  to  a  sudden  noise  by  twitching  the 
body  or  turning  the  head.  Acoustic  memories  are  gradually  stored 
up;  so  that,  by  the  end  of  the  third  month,  the  child  has  almost  com- 
plete control  of  all  its  senses. 

Development  of  Speech. — ^The  child  at  first  can  utter  involuntary 
sounds,  thus  gaining  control  of  the  speech  mechanism.  Gradually 
it  learns  by  hearing  to  reproduce  sounds,  at  first  unconsciously,  until 
finally  conscious  speech  is  acquired.  By  practice  the  child  rapidly 
adds  to  its  vocabulary  which,  according  to  Ziehen,  at  eighteen  months 
should  consist  of  40  words,  by  the  end  of  the  second  year  of  200  to 
300  words.  With  this  rapid  increase  the  child  deepens  his  judgment, 
increases  his  associations,  imitative  instincts,  his  conceptions  of 
personality,  and  gradually  so  develops  that  he  will  speak  of  himself 
in  the  first,  instead  of  the  third  person. 

In  studying  the  morphology  of  the  brain,  its  rapid  increase  in  size 
within  the  first  three  or  four  years  of  life  is  held  to  be  of  the  greatest 
importance.  We  now  see  why  this  is  so.  Functional  development 
is  commensurate  with  this  gross  increase  for,  by  the  end  of  the  third 
or  fourth  year,  the  child  is  able  to  respond  rudely  to  all  stimuli  for 
the  sense  organs,  has  its  motor  functions  to  a  certain  extent  under 
control,  is  able  to  speak,  to  accomplish  simple  associations,  and  has 
a  conception  of  personality  (Craemer).  We  can,  therefore,  readily 
understand  the  great  increase  in  brain  tissue. 

Peculiarities  of  the  Nervous  System  of  the  Child. — Feeble  inhibitory 
tone  is  the  most  important  peculiarity  of  the  child's  nervous  system. 
The  child  responds  to  stimuli  with  increased  reaction  which,  in  the 


772  THE  NERVOUS  SYSTEM 

adult,  would  produce  no  result.  This  function  of  inliibition  being 
the  last  function  of  the  nerve  cell  to  be  developed  is  only  imperfectly 
developed,  owing  to  the  very  extensive  areas  of  the  central  nervous 
system  which  are  undeveloped.  As  the  child  grows  older,  and  its 
nervous  system  develops,  the  inhibitory  tone  increases.  According 
to  Peritz,  this  feeble  physiological  uiliibition  is  shown  by  the  reactions 
of  the  child.  It  desires  everything  it  sees;  it  is  afraid  of  darkness, 
strange  faces,  and  animals;  it  is  easily  frightened.  Feeble  inhibition 
is  also  observed  m  the  child  at  play;  it  runs,  jumps,  kicks,  being 
conscious  of  no  restraint;  all  these  are  evidences  of  a  lack  of  inhibition. 

The  lack  of  inhibitory  tone  is  further  shown  by  the  development 
of  the  child's  imitative  mstinct,  as  it  soon  imitates  the  movements 
of  others.  It  is  further  shoT\'n  in  the  flight  of  ideas  observed  in  chil- 
dren. In  relatmg  stories,  or  in  speakmg,  they  ramble  from  one  thought 
to  another,  just  as  these  thoughts  come  to  them;  this  is  observed  even 
m  older  children.  Lack  of  tone  is  also  shown  by  the  effect  upon  the 
cardiorespiratory  centre.  The  iu crease  in  heart  rate,  the  variable 
quality  of  the  pulse,  and  the  respiratory  changes  show  a  lack  of 
inhibitory  development.  The  newborn  is  sympatheticotonic,  not 
vagotonic. 

Feeble  inhibitory  tone  is  shown  pathologically  m  the  ease  with 
which  sensory  stimuli  call  forth  motor  responses.  This  is  most  clearly 
exhibited  in  the  ease  with  which  convulsions  are  produced  in  chil- 
dren by  gastro-intestinal  disturbances,  intestinal  parasites,  fever, 
etc.  The  stimuli  from  the  peripheral  nerves  are  not  inhibited,  but 
are  diffused  over  the  motor  cortex,  and  produce  convulsions.  Other 
examples  are  the  reflex  symptoms  due  to  phimosis,  eyestrain,  and 
adenoids. 

Another  pathological  evidence  of  feeble  inliibition  is  the  frequency 
of  irregular  muscular  movements  (choreic,  choreiform)  in  children; 
whereas  in  the  adult  these  choreiform  movements,  which  are  compara- 
tively rare,  are  associated  with  definite  cerebral  lesions,  in  children 
this  is  not  the  case,  the  athetosis  and  choreiform  movements  which 
follow  infantile  cerebral  palsies  being  independent  of  any  local  lesion. 
In  the  neiuoses,  the  imitative  instinct  of  the  child  is  pathologically 
developed,  especially  m  the  monosymptomatic  type  of  hysteria  so 
common  in  children,  in  which  the  child  imitates  the  movements  of 
others.  The  sensory  stimuli  from  without  spread  uninhibited  over 
a  whole  motor  cortical  area,  and  evoke  a  response.  The  unusual 
development  of  the  imagination  so  frequently  observed  in  hysteria, 
often  leading  to  lymg,  illusions,  and  hallucinations,  is  another  evidence 
of  this  pathological  lack  of  inhibition  of  the  nervous  system. 

.n.   EXAMINATION    OF    THE   NERVOUS    SYSTEM. 

The -examination  of  the  nervous  system  of  the  child  is  accomplished 
with  considerable  difficulty,  for  children  cannot  localize  definitely 
their  symptoms.    Owmg  to  fright,  the  symptoms  may  be  exaggerated 


EXAMINATION  OF   THE  NERVOUS  SYSTEM  773 

or  falsely  localized.  The  examiner  will  do  well  first  to  gain  the  con- 
fidence of  the  child  before  beginning  the  examination.  Naturally 
all  painful  tests,  such  as  the  electrical,  should  be  made  last.  It  is 
of  the  greatest  importance  in  every  case  to  take  a  complete  history, 
especially  the  family  history,  before  beginning  the  examination.  In 
the  general  examination  of  a  child  much  information  can  be  obtained 
merely  by  inspection;  this  is  also  true  in  the  examination  of  the  nervous 
system,  the  shape,  size,  and  symmetry  of  the  head,  the  facial  expression 
of  the  mentally  defective,  a  flaccid  or  spastic  paralysis,  may  all  be  noted. 

Normal  Reflexes. — The  tendon  reflexes  are  present  at  birth,  become 
active  after  a  few  weeks  and  remain  so  until  the  second  year.  The 
more  common  deep  tendon  reflexes,  such  as  the  patellar,  Achilles, 
triceps,  and  biceps  are  all  evoked  by  holding  the  limb  in  such  a  posi- 
tion as  to  cause  complete  relaxation  of  the  muscles,  and  then  giving 
the  tendon  a  sharp  blow  with  a  percussion  hammer,  whereupon  the 
response  will  follow;  in  the  patellar  tendon  reflex  it  is  extension  of 
the  leg;  in  the  Achilles,  extension  of  the  foot;  in  the  triceps,  extension 
of  the  forearm;  and  in  the  biceps,  flexion  of  the  forearm.  The  majority 
of  the  superficial  skin  reflexes  obtained  by  irritating  the  skin  do  not 
appear  at  birth.  The  abdominal  is  sometimes  observed  about  the 
third  day,  but  is  not  constant  before  the  fifth  month.  The  cremasteric 
and  gluteal  reflexes  appear  at  the  third  month,  but  are  not  constant 
before  the  end  of  the  first  year. 

Abnormal  Reflexes. — 1.  Babinski  Reflex. — This  reflex  is  obtained 
by  irritating  the  outer  margin  of  the  sole  of  the  foot  by  drawing 
some  blunt  object  along  it.  Instead  of  the  normal  plantar  flexion 
of  the  great  toe,  there  is  extension  accompanied  by  a  fan-like  abduction 
of  the  other  toes. 

2.  Oppenheim  Reflex. — This  reflex  is  also  accompanied  by  extension 
of  the  great  toe  and  other  toes,  and  sometimes  the  foot  as  well;  it 
is  obtained  by  making  firm  pressure  downward  along  the  inner  border 
of  the  tibia  with  the  thumb  or  blunt  end  of  a  percussion  hammer. 
In  infants  from  six  to  ten  months  old  this  extension  is  a  normal 
response,  w^hereas  a  positive  Babinski  or  Oppenheim  reflex  after  this 
age  is  indicative  of  a  pathological  process — disease  of  the  pyramidal 
tract. 

3.  Ankle-clonus. — An  ankle-clonus  is  evoked  by  semiflexing  the 
leg,  and  flexing  the  foot  abruptly  dorsalw^ard,  when  a  to-and-fro 
motion  of  the  foot  is  produced. 

4.  Patollar  Clonus. — ^This  is  a  similar  reflex  produced  by  abrupt 
extension  of  the  quadriceps  femoris  muscle  and  on  pushing  the  patella 
abruptly  downward.  Both  the  ankle-  and  patellai  clonus  can  be  pro- 
duced in  very  young  infants.  Peritz  observed  an  ankle-clonus  in 
a  three- weeks-old  infant  suffering  from  meningitis.  A  pseudo-ankle- 
and  patellar  clonus  can  be  elicited  in  neurasthenic  and  hysterical 
children.  Thiemich  states  that  an  ankle-clonus  can  be  obtained  in 
fevers  and  irritable  children  up  to  one  year  of  age  without  any 
pathological  significance. 


774  THE  NERVOUS  SYSTEM 

5.  Kernig's  Sign. — With  the  patient  lying  upon  his  back  and  the 
thighs  flexed,  complete  extension  of  the  leg  at  the  knee-joint  is  impos- 
sible owmg  to  spasticity  of  the  flexor  muscles.  This  is  indicative  of 
meningitis. 

6.  Pniidzinski's  Sign. — This  sign  is  obtained,  after  passive  flexion 
of  the  neck,  with  the  patient  on  his  back.  The  lower  extremities 
will  be  drawn  up,,  there  being  flexion  at  both  the  hip-  and  knee-joints. 
It  is  an  early  sign  in  meningitis. 

The  following  are  elicited  in  spasmophflic  conditions: 

7.  Trousseau's  Phenomenon. — This  is  produced  by  making  pres- 
sure around  the  arm,  best  with  an  elastic  band,  thereby  irritating 
the  large  nerves,  and  causing  the  hand  and  fingers  to  assume  a  tetanic 
position,  the  characteristic  position  in  tetany 

8.  Chvostek's  Sign. — ^This  is  obtained  by  gently  percussing  the 
cheek  along  the  course  of  the  facial  nerve,  best  over  Chvostek's 
point,  which  is  midway  between  the  zygomatic  arch  and  the  angle  of 
the  mouth.  A  clonic  contraction  of  the  muscles  innervated  by  the 
facial  nerve,  the  angle  of  the  mouth,  nose,  eyelid,  and  forehead, 
follows.  If  the  irritability  is  greatly  increased,  this  same  phenomenon 
can  be  elicited  by  stroking  the  cheeks  (Schultz's  phenomenon.) 

9.  Erb's  Phenomenon. — ^This  is  electrically  increased  irritability  of 
the  nervous  svstem.  The  CaCC  is  less  than  normal,  and  mav  appear 
at  0.1  MA.  AnOO  AnCC  both  being  under  5  MA.  CaOC  less 
than  5  MA.  is  pathological. 

Hypotonus. — By  hopotonus  is  meant  a  condition  of  the  muscles 
in  which  the  normal  tension  is  diminished;  consequently  greater 
excursions  can  be  made  by  the  extremities  at  the  joints;  thus,  the  legs 
can  approximate  the  face;  the  heels,  the  buttocks;  and  the  legs  can 
be  drawn  apart  to  an  angle  of  190  degrees.  In  children  up  to  four 
years  of  age  this  hypotonus  is  normal. 

Sensory  Examination. — Sensory  examinations  are  not  easily  carried 
out  in  children,  especially  in  those  under  five  years  of  age,  for  they 
are  not  sufficiently  intelligent  to  differentiate  between  the  finer  tests. 
Very  young  children  are  so  sensitive  to  pin  pricks  that  they  begin' 
to  cr}^  making  further  examination  useless.  Only  in  children  above 
nine  years  of  age  can  we  make  sensory  tests  as  in  the  adult. 

Electrical  Examination. — This  is  carried  out  the  same  as  in  the 
adult;  but  it  requires  considerable  experience  in  order  not  to  confuse 
the  normal  muscular  contractions  with  those  due  to  electrical 
stimuli. 

Reaction  of  Degeneration. — The  typical  reaction  of  degeneration 
consists  of  a  loss  of  excitability  of  both  nerve  and  muscle  to  all  faradic 
stimuli,  and  a  loss  of  excitability  of  the  nerve  to  all  galvanic  stimuli; 
whereas,  galvanic  stimulation  of  the  muscle  calls  forth  an  increased 
response,  i.  e.,  it  reacts  to  a  weaker  current,  or  the  contraction  is 
changed  in  a  typical  manner  so  that,  instead  of  a  quiet,  sharp  con- 
traction, there  is  a  slow,  vermiform,  lazy  contraction  of  the  muscle. 
AnCG  is  excited  more  rapidly  and  appears  before  the  CCC.     This  is 


LUMBAR  PUNCTURE  775 

the  typical  reaction  of  degeneration,  and  denotes  a  lesion  of  either 
the  anterior  horn  cells  or  the  peripheral  motor  nerves. 

Not  Infrequently,  however,  only  a  partial  reaction  of  degeneration 
will  be  present,  and  may  appear  in  various  ways.  There  may  be 
only  diminished  irritability  of  the  nerve  to  both  faradic  and  galvanic 
stimuli,  or  galvanic  stimulation  of  the  nerve  and  direct  faradic  stimu- 
lation of  the  muscle  may  cause  a  slow,  lazy,  muscular  contraction. 
There  may  be  only  diminished  irritability,  of  the  muscle  to  direct 
faradic  stimuli,  the  contraction  being  prompt.  In  these  various  forms 
the  AnCC=  CCC  or  CCC>  AnCC  instead  of  AGO  CCC.  These 
variations,  together  with  the  typical,  slow,  lazy,  vermiform  contraction 
of  the  muscle  after  direct  galvanic  stimulation,  constitute  a  reaction 
of  degeneration. 

m.    LUMBAR    PUNCTURE. 

Lumbar  puncture,  first  described  by  Qaincke  in  1892,  in  the  past 
few  years  has  assumed  such  vast  importance  in  the  diagnosis  and 
treatment  of  all  nervous  and  mental  diseases  that  a  neurological 
study  is  no  longer  complete  without  a  thorough  investigation  of  the 
spinal  fluid. 

Technic. — Puncture  must  naturally  be  performed  under  the  best 
surgical  technic.  Either  the  sitting  or  recumbent  posture  may  be 
employed.  In  the  sitting  position  the  trunk  is  bent  forward,  the 
head  flexed  upon  the  chest,  the  arms  allowed  to  hang  loosely  at  the 
side.  In  the  recumbent  method,  which  in  children  is  preferable, 
because  puncture  in  the  sitting  posture  is  not  free  from  danger  to 
the  little  one,  the  child  is  placed  upon  its  side,  the  knee  and  thighs 
well  flexed,  the  head  and  shoulders  bent  forward,  so  as  to  separate 
the  intravertebral  spaces  as  widely  as  possible.  A  horizontal  Ime 
is  drawn  from  the  crest  of  one  ilium  to  the  other,  passing  the  verte- 
bral column  through  the  spine  of  the  fourth  lumbar  vertebra.  As 
the  cord  in  the  child  is  relatively  long,  in  order  not  to  injure  it,  the 
puncture  should  be  made  between  the  4th  and  5th  lumbar  or  the 
5th  lumbar  and  1st  sacral  vertebrae.  One  either  punctures  directly 
in  the  median  line  or  somewhat  to  the  side,  preferably  the  former. 
The  lower  level  of  the  upper  vertebral  spine  is  located  with  a  finger 
of  the  left  hand,  and  at  this  level  the  instrument  is  thrust  through 
horizontally  instead  of  piercing  the  centre  of  the  intervertebral  space. 
If  punctured  in  the  centre,  then  the  needle  should  be  directed  upward; 
if  punctured  from  the  side,  the  direction  of  the  needle  should  be 
upward,  forward,  and  inward.  One  can  readily  tell  by  the  sudden 
lack  of  resistance  to  the  needle  when  one  has  pierced  the  spinal  canal. 
The  trocar  is  now  withdrawn,  and  the  fluid  allowed  to  flow.  The 
lumen  of  the  needle  may  be  occluded  by  fibrin  or  pus,  or  by  the  pres- 
sure of  the  fibers  of  the  cauda  equina  against  it.  The  former  difficulty 
is  generally  overcome  by  reinserting  the  trocar,  and  in  the  latter  by 
slightly  withdrawing  the  needle.    In  some  cases  it  may  be  necessary 


776  THE  NERVOUS  SYSTEM 

to  administer  a  few  whiffs  of  chloroform  or  to  freeze  the  skin  with 
ethyl  chloride.  Following  the  puncture,  the  child  should  be  kept 
quiet  for  twenty-four  hours.  For  diagnostic  purposes  from  5  to 
10  c.c.  must  be  withdrawn. 

Pressure  of  the  Spinal  Fluid. — Accurate  measurement  of  the  pres- 
sure with  water  or  mercury-  manometers  gives  us  very  little  informa- 
tion. A  relative  idea  can  be  obtained  by  observing  the  flow — ^w'hether 
drop  by  drop,  or  in  a  constant  stream.  Generally  speaking,  the 
pressure  is  increased  in  all  affections  of  the  meninges,  in  brain  and 
spinal-cord  tumors,  hydrocephalus,  hemorrhages,  abscesses,  epilepsy, 
and  eclampsia.  On  the  other  hand,  meningitis  may  be  present  without 
increased  pressure. 

Laboratory  Examination. — The  normal  spinal  fluid  is  as  clear  as 
water,  colorless,  alkaline,  and  of  low  specific  gravity,  1003  to  1007.  Its 
composition  is  as  follows: 

Water,  98.74  per  cent.  Solids,  1.25  per  cent.  Albumin  m  the 
form  of  globulin  and  albumoses,  0.02  to  0.06  per  cent.  Dextrose, 
0.4  to  1  per  cent.  Potassium  salts,  phosphate,  and  urea,  0.15  to  0.35 
per  cent. 

The  laboratory  study  of  the  fluid  should  be  pursued  along  five 
different  lines: 

(1)  Physical,  (2)  Chemical,  (3)  Cytological,  (4)  Serological,  (5)  Bac- 
teriological. 

Examination. 

1.  Physical. — The  spmal  fluid  is  either  clear,  turbid,  opalescent, 
purulent,  or  bloody.  In  all  the  acute  types  of  meningitis,  such  as 
the  epidemic  cerebrospmal,  pneumococcic,  septic,  or  uifluenzal, 
and  in  brain  abscesses,  one  finds  various  grades  of  turbidity  from 
a  slight  degree  to  purulence,  depending  upon  the  acuteness  of  the 
inflammation.  On  the  other  hand,  in  more  chronic  types,  such  as 
tubercular  and  syphilitic  meningitis,  the  fluid  is  usually  clear.  In 
tubercular  meningitis,  the  fluid,  although  usually  clear  in  the  begin- 
ning, may  quickly  become  turbid,  according  to  the  degree  of  inflam- 
mation.    In  intraventricular  hemorrhage,  the  fluid  may  be  bloody. 

2.  Chemical  Examination. — Albumin. — Xonne,  Ross-Jones,  Xoguchi, 
Kaplan,  and  Lange  have  all  described  tests  for  detecting  albumin. 
Only  Kaplan's  will  be  detailed  here. 

Kaplan's  Test. — After  boiling  5  c.c.  of  spinal  fluid  in  a  test-tube 
1  cm.  in  diameter,  2  drops  of  a  5  per  cent.  but\Tic  acid  solution  in 
normal  saline  are  added,  and  it  is  boiled  again.  After  boiling  the 
second  time  0.5  c.c.  of  a  supersaturated  solution  of  ammonium  sulphate 
is  underfloated  by  means  of  a  pipette.  After  being  allowed  to  stand 
for  twenty  minutes,  an  excess  manifests  itself  in  the  form  of  a  thick, 
granular  cheesy  ring  at  the  point  of  contact.  Kaplan  gets  a  relative 
idea  of  the  globulin  increase  by  making  tests  of  different  dilutions: 
0.5,  0.4,  0.3,  0.2,  0.1,  and  by  adding  distilled  water  up  to  0.5  c.c.  to 
the  tubes  containing  less  than  0.5  c.c.  of  spinal  fluid. 


LUMBAR  PUNCTURE  777 

Dextrose. — The  reducing  substance  is  sugar,  which  is  detected 
by  means  of  Fehling's  test. 

An  increase  in  globuhn  generally  accompanies  any  inflammatory 
condition  of  the  meninges,  and  is  also  present  in  spinal  cord  tumors, 
without  cellular  increase. 

Fehling's  reduction  is  a  normal  reaction  of  the  spinal  fluid.  It 
is  also  present  in  the  more  chronic  type  of  meningeal  inflammation 
as  juvenile  tabes,  paresis,  cerebrospinal  syphilis,  and  sometimes  as 
tubercular  meningitis.  It  is  not  found  in  any  of  the  acute  forms  of 
meningitis. 

3.  Cytological  Examination. — Normally  from  one  to  five  lymphocytes 
per  c.cm.  are  present  in  the  spinal  fluid.  Their  study  is  of  the  utmost 
importance,  inasmuch  as  there  may  be  pathologically  a  great  increase 
in  cellular  elements.  There  are  three  methods  in  use  for  the  study  of 
these  cellular  elements:  (1)  The  French  method;  (2)  the  Fuchs- 
Rosenthal  method;  (3)  the  Alzheimer  method. 

The  French  Method. — This  consists  in  centrifuging  5  c.c.  of  spinal 
fluid  for  from  20  to  30  minutes.  After  pouring  oft'  the  supernatant 
fluid,  the  sediment  is  withdrawn  by  means  of  a  fine  capillary  tube, 
placed  on  a  slide,  and  stained  for  study.  Only  a  relative  idea  of  the 
cellular  increase  can  be  obtained  by  this  method. 

Fuchs- Rosenthal  Method. — ^This  consists  in  counting  the  cells  upon 
a  special  counting  chamber;  that  is,  a  modified  blood-counting  chamber 
whose  area  consists  of  16  sq.  mm.,  and  depth  0.5  mm.  This  is  the 
best  method  for  obtaining  an  accurate  estimate  of  the  number  of  cells. 

Alzheimer  Method. — This  method  is  employed  for  cytological  study, 
and  consists  in  embedding  in  celloidin  the  sediment  obtained  by 
centrifuging  the  spinal  fluid,  then  cutting,  mounting,  and  finally 
staining  the  sections  for  study.  By  this  method  the  finer  cytological 
studies  can  be  made. 

In  all  forms  of  meningeal  irritation  and  inflammation  there  is  cellu- 
lar increase.  Either  the  lymphocytes  or  polynuclear  leukocytes 
predominate  according  to  the  acuteness  of  the  inflammation.  Conse- 
sequently  in  all  acute  types  of  meningitis  we  have  a  predominance 
of  polynuclear  elements;  whereas,  in  the  more  chronic  type — spinal 
syphilis,  juvenile  tabes,  and  paresis — the  lymphocytes  predominate. 
In  tubercular  meningitis  there  is  generally  a  lymphocytosis  in  the 
earlier  stages;  but  subsequently  the  polymorphonuclear  elements 
predominate,  frequently  forming  as  high  as  90  per  cent,  of  the  total 
number  of  cells.  In  brain  tumor  (non-syphilitic),  the  endarteritic 
type  of  cerebral  syphilis,  hydrocephalus,  and  spinal  cord  tumors, 
there  is  a  negative  cell  count. 

4.  Serological  Examination. — In  all  neurological  cases  there  should 
be  a  Wassermann  reaction  made  of  the  spinal  fluid,  as  well  as  of  the 
blood  serum.  In  cases  of  paresis,  there  is  generally  a  positive  Wasser- 
mann reaction  in  both  fluid  and  serum;  in  tabes,  the  reaction  in  the 
fluid  is  positive  in  60  per  cent.  (Nonne) ;  it  is  generally  negative  in 
cerebrospinal  syphilis  (Plaut). 


778  THE  NERVOUS  SYSTEM 

5.  Bacteriological  Examination. — JMicroscopic  preparations  should  be 
made  of  all  spinal  fluids  in  order  to  examine  them  for  bacteria. 
The  Diplococcus  intracellularis  meningitidis  is,  as  its  name  signifies, 
an  mtracellular  diplococcus  which  does  not  retam  the  Gram  stain. 
Tubercle  bacilli  are  best  found  by  making  dry  preparations  of  the 
web-like  coagulum  of  fibrin  which  usually  collects  in  the  test-tube 
after  standing  for  some  time.  The  coagulum  is  well  teased  out  upon 
a  slide,  and  then  stamed  for  the  tubercle  bacilli.  ^Mien  a  coagulum 
does  not  form  the  fluid  should  be  centrifuged,  so  that  the  bacteria 
will  settle  in  the  sediment.  It  often  requires  long  diligent  search 
to  find  them,  and  repeated  examinations  from  later  punctures  may 
have  to  be  made  before  they  are  found.  Cultures  should  always  be 
made  and,  whenever  in  doubt,  animal  inoculations  as  well. 

IV.    CRANIAL   AND    CEREBRAL   PUNCTURE. 

(Neisser,  Pollack,  Pfeiffer.) 

This  is  performed  for  both  therapeutic  and  diagnostic  purposes. 
It  is  easily  done  in  infants,  for  the  fontanelle  membranes  can  "be  punc- 
tured without  trephining.  To  avoid  the  sinus  longitudinal  superior, 
the  needle  is  thrust  1  to  2  cm.  laterally  from  the  sagittal  suture 
directly  through  the  fontanelle  membrane.  The  trocar  is  then  with- 
drawn, w^hen,  if  fluid  be  present,  it  will  flow  out.  Clear  fluid  is  indica- 
tive of  external  hydrocephalus,  and  bloody  fluid  of  pachymeningitis 
interna  hemorrhagica.  Should  one  desire  to  aspirate  the  lateral  ven- 
tricles, the  needle  is  thrust  in  a  few  centimeters  farther  along  in  their 
direction.  These  procedures  are  made  use  of  m  the  diagnosis  and 
treatment  of  internal  and  external  hydrocephalus  and  pachymenin- 
gitis interna  hemorrhagica.  In  older  children  in  whom  the  sutures 
and  fontanelles  have  closed,  the  point  of  entrance  must  be  trephined, 
and  the  whole  procedure  carried  out  under  the  strictest  surgical 
technic. 


DISEASES   OF  THE   SPINAL  CORD. 

MALFORMATIONS. 

Malformations  of  the  spmal  cord  are  frequently  associated  with 
those  of  the  brain,  with  defects  of  the  skull,  and  of  the  vertebral 
column,  as  well  as  with  malformations  in  other  parts  of  the  body; 
viz.,  ectopia  of  the  bladder  and  congenital  hernia.  INIalformations  of 
the  spinal  cord  may  be  grouped  as  follows: 

1.  Amyelia — entire  absence  of  the  cord. 

2.  Atelomyelia — partial  development  of  the  cord. 

3.  Diastematomyelia  and  diplomyelia — the  division  and  redupli- 
cation of  the  cord. 

4.  Heterotopia — the  malposition  of  some  of  the  gray  matter. 


MYELITIS  ll'd 

All  of  these  varieties  are  exceedingly  rare,  and  of  little  interest.. 

5.  Spina  bifida. — By  "spina  bifida"  is  meant  all  congenital  defects 
of  the  vertebral  column,  these  being  most  frequently  present  poste- 
riorly in  the  vertebral  arches,  but,  more  rarely,  anteriorly  in  the  body 
of  the  vertebra. 

Accordmg  to  Marchand,  there  are  two  kinds  of  spina  bifida:  (1)  the 
closed  form,  spina  bifida  cystica;  and  (2)  the  open  form,  rachischisis. 

All  of  these  malformations,  excepting  rachischisis,  have  been  consid- 
ered in  Chapter  VI  on  Congenital  Malformations  (see  pages  100-103) . 

Rachischisis.— In  rachischisis,  which  may  affect  either  the  whole  or 
a  part  of  the  vertebral  column,  there  is  an  open  fissure  which  exposes 
the  posterior  surface  of  the  body  of  the  vertebra  together  with  a  part 
of  the  inner  layer  of  the  pia  and  spinal  marrow.  At  the  border  of 
the  cleft,  the  skin,  fascia,  muscles,  bone,  dura,  and  pia  terminate 
abruptly.  In  embryonal  life  the  spinal  portion  of  the  medullary 
groove  remains  patent. 

MYELITIS. 

Myelitis,  other  than  acute  anterior  poliomyelitis  and  compression 
myelitis,  is  very  rare  in  childhood.  Adults  and  children  react  quite 
differently  to  inflammation  of  the  cord.  In  the  child  poliomyelitis  is 
the  characteristic  manifestation,  whereas  in  the  adult  it  is  myelitis. 
The  other  types  of  myelitis,  though  rarely  seen,  are  transverse  mye- 
litis, Landry's  ascending  paralysis,  and  disseminated  encephalomye- 
litis. Vascular  changes  in  the  cord  are  also  included  under  this  head- 
ing, for  anatomically  and  clinically  they  cannot  be  differentiated. 

Myelitis  may  follow  any  infectious  disease,  and  may  complicate 
a  syphilitic  or  tubercular  infection.  Certain  poisons,  such  as  gas  and 
arsenic,  are  known  to  produce  the  disease.  Numerous  bacteria  have 
been  isolated  from  the  cord,  but  none  specific.  According  to  Bruns, 
the  disseminated  encephalomyelitis  is  the  most  frequent  type,  the 
transverse  myelitis  and  Landry's  ascending  paralysis  being  very  rare. 
Disseminated  encephalomyelitis  and  Landry's  ascending  paralysis  are 
described  under  separate  headings. 

Transverse  Myelitis. — This  disease  usually  sets  in  slowly  after 
some  previous  infection,  with  moderate  fever,  general  malaise,  weak- 
ness, pains  or  paresthesia,  loss  of  appetite,  and  a  slowly  developing 
paralysis.  On  the  other  hand,  the  paralysis  may  develop  suddenly, 
as  an  apoplectiform  attack.  As  a  result  of  the  inflammation,  there 
are  sensory,  motor,  and  trophic  disturbances.  Of  the  sensory  symp- 
toms there  may  be  either  pains — girdle  pains — due  to  irritation  of  the 
posterior  roots,  or  anesthesia,  or  paresthesia. 

Motor  symptoms  may  be  as  follows:  (1)  Clonic  muscular  spasms 
from  irritation  of  the  anterior  roots.  (2)  A  flaccid  paralysis  at  the 
level  of  the  lesion.  (3)  A  spastic  paralysis  below  the  level  of  the 
lesion  with  exaggerated  reflexes,  ankle  and  patellar  clonus,  an  absence 
of  muscle  atrophy  and  the  reaction  of  degeneration,  with  positive 
Oppenheim,  Babinski,  and  Mendel-Bechterew  phenomena. 


780  THE  NERVOUS  SYSTEM 

Of  the  trophic  distui-bances  there  are:  (1)  i\.trophy  of  the  muscles 
at  the  level  of  the  lesion  with  an  accompanying  reaction  of  degenera- 
tion. (2)  Bladder  and  rectal  disturbances  with  secondary  cystitis, 
cystopyelitis,  and  nepln-itis.  (3)  Decubital  ulcers.  The  local  s\Tiip- 
toms  vary  according  to  the  location  and  extent  of  the  lesion.  When 
situated  in  the  lumbar  portion  of  the  cord,  there  is  a  flaccid  paralysis 
of  the  lower  extremities,  with  muscular  atrophy,  loss  of  reflexes,  loss 
of  sensation  up  to  the  level  of  the  lesion,  girdle  sensations  at  the  level, 
sphincter  disturbances,  and  decubital  ulcers. 

When  the  lesion  is  situated  in  the  thoracic  region — its  most  frequent 
location — there  is  spastic  paralysis  involving  the  lower  extremities, 
with  exaggerated  reflexes,  ankle  and  patellar  clonus,  Oppenheim  and 
Babinski  phenomena,  anesthesia  up  to  the  level  of  the  lesion  with 
girdle  pains  above  it,  sphincter  disturbances,  and  decubital  ulcerations. 
When  the  lesion  is  located  in  the  upper  thoracic  and  lower  cervical 
regions,  there  may  be  a  flaccid  paralysis  of  the  arms,  with  loss  of 
reflexes,  and  muscular  atrophy  with  spasticity  of  the  trunk  muscles 
and  lower  extremities.  When  situated  in  the  upper  cervical  portion, 
in  addition  to  spastic  paralysis  of  both  lower  and  upper  extrem- 
ities, there  are  oculopupillary  disturbances,  also  interference  with 
respiration  due  to  involvement  of  the  phrenic  nerve. 

A  lesion  may  be  so  circumscribed  as  to  give  unilateral  symptoms, 
leading  to  monoplegia.  The  typical  Brown-Sequard  syndrome  may 
be  present  in  rare  cases.  Occasionally  a  transverse  myelitis  may  be 
so  extensive  as  to  give  rise  to  a  complete  transverse  lesion,  in  which 
event  there  is  flaccid  paralysis  and  loss  of  reflexes  below  the  level  of 
the  lesion.  The  symptom-complex  may  be  further  complicated  by 
the  presence  of  multiple  disseminated  foci  which  extend  over  the  whole 
central  nervous  system. 

Prognosis. — ^The  prognosis  is  unfavorable.  Death  is  due  either  to 
involvement  of  the  respiratory  centre  or  to  complications,  such  as 
intercurrent  infections,  cystitis,  or  decubital  ulcers.  However,  marked 
improvement  and  even  recovery  may  take  place.  This  is  usually 
observed  in  disseminated  encephalomyelitis. 

Treatment. — During  the  acute  stage  the  patient  should  be  kept  in 
bed,  and  care  taken  to  prevent  bed-sores  and  cystitis.  Electricity 
and  all,  skui  irritants  are  contra-indicated.  Warm  baths  will  relieve 
the  spasmodic  contractions  of  the  muscles.  Sedatives,  such  as  sodium 
bromide,  must  be  administered  frequently.  ^Mien  convalescence  sets 
in  the  galvanic  current  should  be  applied  along  the  spinal  column 
and  over  the  atrophied  muscles.  When  the  patient  begins  to  regain 
the  use  of  his  paralyzed  muscles,  moderate  massage  and  gymnastic 
exercises  should  be  prescribed,  and  Frenkel's  reeducation  movements 
taught.  Improvement  may  follow  the  admmistration  of  potassium 
idodide.  In  all  cases  m  which  s\T)hilis  is  the  etiological  factor,  anti- 
s^'philitic  treatment  should  be  instituted  at  once.  In  addition,  certain 
orthopedic  appliances  may  be  necessary. 


CARIES— SPONDYLITIS    TUBERCULOSA— POTT'S   DISEASE     781 

Compression  Myelitis. — The  spinal  cord  may  be  compressed  by 
affections  which  involve  the  meninges  of  the  cord,  such  as  a  tumor, 
or  spinal  meningitis,  or  the  vertebrae  themselves.  By  far  the  most 
frequent  cause  is  caries  of  the  vertebrae.  Rarer  causes  are  dislocations, 
fractures,  tumors,  syphilis,  arthritis  deformans,  acute  spondylitis 
due  to  rheumatic  fever,  osteomyelitis,  and  typhoid  fever.  The  author 
has  recently  observed  a  case  of  beginning  compression  myelitis  due 
to  arthritis  deformans  in  a  little  girl,  six  years  of  age. 

CARIES— SPONDYLITIS    TUBERCULOSA— POTT'S    DISEASE. 

Etiology. — Myelitis  due  to  caries  of  the  vertebrae  is  a  disease  of  early 
childhood,  beginning  usually  between  four  and  eight  years  of  age. 
It  may,  however,  appear  in  early  infancy,  or  may  be  delayed  until 
puberty  or  adolescence.  It  is  usually  secondary  to,  and  combined 
with  tubercular  disease  elsewhere  in  the  body,  as  the  lungs,  other 
bones,  joints,  or  glands.  It  may  develop  spontaneously  or  following 
traumatism. 

Pathological  Anatomy. — Although  usually  secondary  to  tuberculosis 
elsewhere  in  the  body,  the  primary  vertebral  focus  of  infection  is  in 
the  body  of  one  or  more  of  the  vertebrae.  The  tubercle  bacillus 
causes  the  formation  of  spongy  granulation  tissue  which,  by  disin- 
tegration of  the  bony  tissue,  leads  to  a  secretion  of  thick  material 
resembling  pus.  This  may  continue  until  there  is  complete  softening 
of  the  body  of  the  vertebrae  when,  on  removal  of  the  support,  the 
overlying  vertebrae  sink  in,  and  produce  a  characteristic  angular 
projection  of  the  spinous  process — kyphosis. 

Compression  of  the  cord  is  not  usually  due  directly  to  compression 
of  the  vertebrae,  but  to  a  narrowing  of  the  spinal  canal  and  compression 
by  the  thickened  dura.  The  adjacent  dura  becomes  inflamed,  both 
as  an  internal  and  external  pachymeningitis,  and  becomes  greatly 
thickened.  The  pressure  of  this  tubercular  mass  upon  the  cord,  causes 
edema  by  interfering  with  the  free  flow  of  blood  and  lymph,  giving  rise 
to  anemia  sufficient  to  cause  different  grades  of  degenerative  changes 
in  the  cord.  Generally  this  mass  is  located  anteriorly,  but  may  sur- 
round the  cord.  More  rarely,  sudden  compression  of  the  cord  is  due 
to  dislocation  of  a  vertebra. 

The  lumbar,  dorsal,  and  cervical  vertebrae  are  most  frequently 
involved,  in  the  order  mentioned  (Schmaus).  Compression  symp- 
toms are  present  in  80  per  cent,  of  the  cases  of  the  dorsal  and  cervical 
varieties,  but  are  less  common  in  the  lumbar  and  sacral  varieties 
(Schmaus) .  Microscopic  examination  shows  degeneration  of  the  tracts 
and  nerve  roots  compressed.  Following  the  edema  there  is  swelling 
of  the  axis  cylinder,  later  degeneration  of  the  nerve  fibers. 

Symptomatology. — The  symptoms  may  arise  from  the  side  of  the 
bones,  the  nerve  roots,  or  the  spinal  cord.  The  earliest  symptom 
is  pain  over  the  involved  vertebrae,  this  being  increased  by  motion 
or  compression.     In  children  pain  may  be  absent;  and,  as  a  result, 


782  THE  NERVOUS  SYSTEM 

in  order  to  produce  fixation  of  the  joint,  there  is  reflex  muscular  con- 
traction. Irritative  root  symptoms  are  not  so  extensive,  but  form  an 
early  symptom  of  the  disease,  the  pain  being  sharp,  lancinating  in 
character,  and  distributed  over  the  course  of  the  affected  nerve.  The 
paral3i:ic  sj-mptoms,  the  result  of  compression,  depend  upon  the  point 
of  compression. 

At  first  there  is  muscular  weakness;  but,  as  the  pressure  advances, 
the  picture  of  transverse  myelitis  develops,  differing  from  the  latter 
in  that  sensory  disturbances  are  much  in  abeyance.  Touch  and 
temperature  may  be  affected;  pain  and  muscle  sense  are  usually 
intact.  Sphincter  disturbances  are  generally  absent  until  late  in 
the  course  of  the  disease.  As  the  compression  usually  affects  the 
thoracic  region,  there  follows  a  spastic  paraplegia  of  the  lower  extrem- 
ities, with  increased  reflexes,  ankle-  and  patellar  clonus,  Oppenheim 
and  Babinski  phenomena,  and  anesthesia  of  varying  degree  up  to 
the  level  of  the  compression,  where  there  is  an  area  of  hyperes- 
thesia. 

Severe  girdle  pains  may  appear  as  well  as  sphincter  and  trophic 
disturbances.  (For  the  symptoms  of  compression  on  other  parts 
of  the  cord,  see  chapter  on  ^Myelitis.)  When  the  upper  cervical  ver- 
tebrae, the  atlas,  and  the  axis  are  involved  there  is  usually  marked 
bilateral  occipital  neuralgia.  In  addition  bulbar  palsies  are  frequent. 
Respiration  is  also  endangered  from  involvement  of  the  respiratory 
center. 

Diagnosis. — The  presence  of  a  deformity,  of  localized  pain,  espec- 
ially on  percussion  over  the  vertebrae,  neuralgic  girdle  pain,  rigidity 
of  the  spinal  column,  together  with  any  paralysis,  usually  establishes 
the  diagnosis.  X-rays  and  the  different  tuberculin  tests  may  assist. 
In  the  earlier  stages,  before  the  characteristic  picture  has  been  com- 
pleted, since  one  or  more  symptoms  may  be  lacking,  it  must  be  diflFer- 
entiated  from  tumors  of  the  spinal  cord  and  vertebrae,  s\'philis  of 
the  vertebrae,  spondylitis  due  to  the  Bacillus  t^'phosus,  or  an  acute 
osteomyelitis,  rickets,  or  rheumatic  fever.  Hysteria  and  neurasthenia 
may  also  be  mistaken  for  this  disease. 

Course  and  Prognosis. — The  course  of  myelitis  due  to  Pott's  disease 
is  usually  slow  and  chronic,  extending  over  a  number  of  years.  The 
prognosis  naturally  depends  upon  the  extent  of  tubercular  involve- 
ment in  the  rest  of  the  body,  and  upon  the  treatment.  In  many 
cases  early  symptoms  develop  long  before  there  is  paralysis,  and  if 
appropriate  treatment — i.  e.,  fixation — is  begun  when  the  diagnosis 
is  made,  paralysis  may  be  averted.  Under  proper  fixation  the  paral- 
ysis which  occurs  early  in  the  disease  quickly  passes  away.  WTien, 
however,  paralysis  develops  during  treatment,  the  progress  is  unfavor- 
able. Relapses  are  frequent  in  later  life,  being  accompanied  by 
palsies,  which  do  not  occur  in  the  earlier  attacks. 

Gibney's  records  show  recovery  in  50  per  cent,  of  his  cases,  and 
death  in  20  per  cent.,  whereas  Peritz  estimated  his  at  30  per  cent, 
of  recoveries  and  60  per  cent,  of  deaths. 


LANDRY'S  PARALYSIS— ACUTE  ASCENDING  PARALYSIS      783 

Treatment. — The  treatment  consists,  first,  of  rest  in  bed,  removal 
of  the  pressure,  and  fixation  of  the  spine  by  proper  orthopedic  appH- 
ances  or  by  bone  transplantation;  secondly,  in  the  alleviation  of  the 
symptoms.  Many  of  these,  such  as  neurotic  pains  and  muscular 
rigidity,  are  relieved  by  proper  fixation.  In  addition,  sedatives  may 
be  required.  Hot  and  cold  douches,  and,  when  possible,  packs  applied 
to  the  spine,  promote  free  circulation  in  the  spinal  cord. 

General  measures,  such  as  plenty  of  fresh  air,  especially  sea  air, 
forced  feeding,  the  administration  of  cod-liver  oil  and  general  tonics, 
are  extremely  important.  Electricity  and  treatment  with  tuberculin 
have  been  ineffectual.  The  utmost  care  should  be  taken  to  prevent 
bed-sores. 

LANDRY'S   PARALYSIS— ACUTE    ASCENDING   PARALYSIS. 

This  rare  disease  was  described  by  Landry  in  1859.  Following 
premonitory  symptoms,  such  as  general  malaise,  fever,  pain  in  the 
extremities,  and  paresthesias,  extending  over  a  period  of  several 
days,  paralysis  appears  in  the  toes  and  feet,  and  within  a  few  hours 
extends  over  the  entire  limb.  After  a  brief  interval  the  paralysis 
spreads  rapidly  upward,  involving  the  muscles  of  the  back,  thorax, 
arms,  and  neck.  Deglutition  and  speech  are  interfered  with,  also  the 
respiration,  as  shown  by  Cheyne-Stokes  breathing.  Usually  there  are 
short  pauses  in  the  progress  before  the  paralysis  is  complete.  Bulbar 
paralyses  do  not  usually  appear,  owing  to  the  rapidity  of  the  process; 
although  facial  and  ocular  palsies  have  been  reported.  Paralysis 
may  develop  within  twenty-four  to  forty-eight  hours,  and  occasionally 
proves  fatal  in  that  time,  or  it  may  be  two  to  three  weeks  reaching 
its  maximum. 

The  paralysis  is  always  flaccid.  The  reflexes  may  be  absent,  but 
are  never  exaggerated.  Electrical  disturbances  are  not  usually 
found.  Slight  sensory  disturbances,  such  as  paresthesia  and  partial 
anesthesia,  are  often  present.  Muscular  atrophy,  and  sphincter  and 
trophic  disorders  do  not  appear.  The  consciousness  remains  clear 
until  the  end. 

Instead  of  its  usual  ascending  course,  the  disease  may  set  in  with 
bulbar  paralysis,  then  rapidly  extend  downward  over  the  arms  and 
trunk.    In  this  type,  death  may  take  place  before  the  legs  are  involved. 

In  its  nature  the  disease  is  an  acute  intoxication  involving  the 
medulla  oblongata  and  spinal  cord,  and  in  some  cases  the  spinal  roots 
and  peripheral  nerves.  Splenic  enlargement  is  frequently  observed. 
It  has  been  described  as  a  clinical  form  of  acute  poliomyelitis.  The 
disease  sometimes  follows  certain  infectious  diseases;  viz.,  typhoid 
fever,  diphtheria,  influenza,  anthrax,  w^hooping-cough,  and  syphilis. 

Pathological  Anatomy. — Formerly  the  pathological  findings  were 
thought  to  be  negative,  but  now  finer  methods  of  examination  show 
a  diffuse  and  disseminated  myelitis  with  changes  especially  prom- 
inent about  the  bloodvessels,  viz.,  thrombosis  with  softening,  hemor- 


784  THE  NERVOUS  SYSTEM 

phages,  and  round-cell  infiltration  leading  to  changes  in  the  nerve 
fibers,  particularly  to  a  swelling  of  the  axis-cylinder.  These  changes 
are  usually  diffuse.  In  other  cases,  neuritis  of  the  nerve  roots  and 
peripheral  nerves  has  been  observed.  Numerous  non-specific  organ- 
isms have  been  found  in  the  gray  matter  of  the  medulla  and  cord. 

Diagnosis. — The  diagnosis  of  the  malady  is  usually  easy,  consider- 
ing the  rapidity  of  its  course.  Peripheral  neuritis,  acute  poliomye- 
litis, and  spinal  infantile  muscular  atrophy  must  all  be  differentiated 
from  it. 

Course  and  Prognosis. — ^The  course  of  the  disease  is  most  frequently 
fatal,  death  taking  place  within  three  to  seven  days,  either  from 
asphyxia  or  secondary  aspiration  pneumonia.  Arrest  of  the  disease 
may,  however,  be  observed  at  any  stage. 

Treatment. — Great  care  must  be  exercised  to  prevent  aspiration 
pneumonia.  If  the  patient  is  not  too  weak,  hot  packs  should  be 
given.  Counter-irritation  with  the  cautery  has  been  recommended. 
If  sj-philis  is  suspected,  mercury  should  be  begun  at  once.  Ergotin, 
also,  has  been  recommended;  otherwise  the  treatment  is  the  same 
as  for  myelitis. 

ACUTE   ANTERIOR   POLIOMYELITIS— INFANTILE   PARALYSIS. 

Definition. — Acute  anterior  poliomyelitis  is  an  infectious  disease 
of  the  central  nervous  system,  appearing  either  epidemically  or 
sporadically,  usually  affecting  very  young  children,  and  giving  rise 
to  a  flaccid  paralysis.  This  is  followed  by  gradual  improvement; 
but,  as  a  rule,  some  permanent  paralysis  remains  in  certain  muscles 
which  undergo  atrophy. 

History. — The  best  early  clinical  description  of  this  disease  was 
by  Heine,  in  1840.  ]\Iedin  described  it  in  1890,  and  demonstrated 
that  it  occurred  epidemically.  Since  that  date  numerous  epidemics 
have  occurred  in  this  country,  Norway,  Sweden,  France,  Italy, 
Austria,  Germany,  and  Australia.  Formerly,  as  the  name  implies, 
the  disease  was  thought  to  be  one  of  the  anterior  horn  cells;  but  since 
the  epidemic  in  Sweden,  in  1905,  dining  which  Wickmann  demonstrated 
various  clinical  varieties  of  the  disease,  our  conception  of  it  has  been 
broadened,  and  we  now  know  that  the  lesion  is  not  confined  to  the 
spinal  cord,  but  extends  to  the  pons,  medulla,  midbrain,  cerebrum, 
and  meninges. 

\Yickmann  not  only  described  the  pathology  and  epidemiology  of 
the  disease,  but  was  the  first  to  describe  the  abortive  type  of  polio- 
myelitis. In  1909,  the  disease  was  produced  experimentally  in  mon- 
keys by  Flexner  and  Lewis,  Landsteiner  and  Popper,  and  by  Strauss, 
In  the  same  year,  working  independently,  Flexner  and  Lewis,  Leiner 
and  von  "Wiesner,  and  Landsteiner  and  Levadii,  reproduced  the  disease 
in  monkeys,  transmitting  it  from  one  monkey  to  another.  Finally,  in 
1913,  Flexner  and  Noguchi  cultivated  the  infecting  organism,  and  have 
since  established  the  fact  that  it  is  the  cause  of  the  disease. 


ACUTE  ANTERIOR  POLIOMYELITIS— INFANTILE  PARALYSIS    785 

Etiology  and  Epidemiology. — Numerous  epidemics  within  the  past 
decade  have  materially  enriched  our  knowledge  and  conception  of 
the  malady.  It  is  essentially  a  disease  of  early  childhood,  occurring 
most  frequently  within  the  first  three  years  of  life,  although  adults 
are  occasionally  affected.  The  time  of  greatest  predisposition  to  it  is 
during  the  latter  half  of  the  second  year.  The  following  table,  in 
part  taken  from  that  of  Frauenthal  and  Manning,  shows  the  relative 
age  of  onset: 


Ages. 

Wickmann, 
Sweden, 

190.5. 
Per  cent. 

Manning, 
Wisconsin, 

1908. 
Per  cent. 

Lovett, 

Massachusetts, 

1909. 

Per  cent. 

0  to  5  years 

.       .       .      40.6 

49.8 

71.5 

6  years  and  over    . 

.       .       .      59.4 

50.2 

28.5 

Ages. 

■     New  York  City, 
1907. 
Per  cent. 

Rockefeller 
Institute, 

1911. 
Per  cent. 

Muller, 

Hesse-Nassau. 

Per  cent. 

0  to  5  years 

.      .      .     90.5 

89.0 

90.0 

6  years  and  over    . 

.      .      .        9.5 

11.0 

10.0 

Both  sexes  are  equally  affected.  Epidemics  occur,  especially  during 
the  summer  months,  reaching  their  maximum  in  late  summer  or 
early  autumn.  The  disease  predominates  in  the  country  rather  than 
in  the  city.  It  has  been  known  to  follow  practically  all  of  the  acute 
diseases,  especially  pneumonia  and  measles,  but  usually  the  children 
attacked  have  previously  been  perfectly  healthy.  Other  exciting 
factors  which  have  lowered  the  patient's  resistance  and  made  him 
more  susceptible  to  infection  have  been  exposure  to  cold  and  damp- 
ness, overexertion,  and  trauma.  One  epidemic  usually  renders  a 
community   immune. 

The  infectious  nature  of  the  disease  has  now  been  definitely  estab- 
lished by  the  cultivation  of  the  infecting  microorganism  by  Flexner 
and  Noguchi,  and  the  experimental  production  of  the  disease  in  mon- 
keys by  inoculation  of  the  cultures  which  had  previously  passed 
through  a  number  of  artificial  media  for  a  period  of  eighteen  months. 
The  microbic  agent,  or  virus,  consists  of  minute  globular  bodies  which 
are  stainable  and  visible  under  the  high  power  of  the  microscope..  It 
is  a  filterable  organism,  and  is  resistant  to  the  action  of  glycerin, 
to  freezing,  to  a  0.5  per  cent,  solution  of  carbolic  acid,  and  to  ordinary 
degrees  of  heat. 

Mode  of  Infection. — From  the  work  of  Flexner  and  Lewis  it  seems 
well-established  that  the  upper  respiratory  tract  is  the  port  of  entrance 
of  the  disease.  The  lymphatics  of  the  nasal  mucosa  which  pass  out 
with  the  filaments  of  the  olfactory  nerve  are  directly  connected  with 
the  meninges,  and  carry  the  infecting  organisms  to  the  spinal  fluid. 
The  virus  is  also  given  off  through  the  nasopharyngeal  mucosa. 

There  are  two  diverse  views  as  to  the  mode  of  infection:     (1)  By 
means  of  the  stable  fly  (Stomoxys  calcitrans),  as  expounded  by  Rosenau; 
(2)  by  personal  contact.    According  to  Flexner,  from  the  evidence  at 
50 


786  THE  NERVOUS  SYSTEM 

hand  the  virus  is  present  in  the  nasal  and  buccal  secretions.  Those 
who  suffer  from  the  disease  transmit  it  by  implanting  the  virus  upon 
the  upper  nasal  mucosa  of  other  susceptible  persons  who  then  develop 
an  attack.  Those  who  suffer  from  the  abortive  type  of  poliomyelitis 
spread  it  in  the  same  manner.  In  addition  there  are  (1)  healthy 
carriers  who  have  been  in  intimate  contact  with  patients;  also  (2) 
chronic  carriers  who  have  recovered  from  an  acute  attack  but  who, 
even  after  the  lapse  of  several  months,  are  capable  of  transmitting 
the  disease.  Moreover,  it  may  be  conveyed  by  certain  passive  agents, 
such  as  clothing  and  dust,  also  by  domestic  animals,  flies,  and  insects, 
for  the  virus  is  known  to  be  very  resistant. 

One  infection  with  poliomyelitis  confers  an  active  immunity  upon 
the  patient.  Immune  bodies  are  formed,  which  are  readily  demon- 
strated biologically  by  the  neutralization  of  active  virus  by  the  blood 
serum  of  a  patient  who  has  recovered  from  the  disease.  This  neutral- 
ized virus  will  not  reproduce  the  disease  experimentally  in  monkeys; 
that  is,  the  active  virus  has  now  become  absolutely  inactive.  The 
neutralization  test  is  of  the  greatest  importance  in  the  diagnosis 
of  the  abortive  type  of  poliomyelitis. 

Pathological  Anatomy. — That  the  virus  gains  access  to  the  body 
through  the  upper  respiratory  passages,  and  is  carried  by  the  lym- 
phatics along  the  filaments  of  the  olfactory  nerve  to  the  cerebrospinal 
fluid,  is  shown  by  the  earliest  pathological  changes  observed  in  the 
central  nervous  system.  There  is  hyperemia,  also  a  mononuclear 
collection  of  cells  in  the  perivascular  lymph  spaces  of  the  bloodvessels 
of  the  pia-arachnoid  which  communicate  with  the  cerebrospinal  fluid. 
This  cellular  infiltration  is  conspicuous  along  the  anterior  surface  of 
the  cord,  especially  about  the  anterior  fissure.  The  pathological  pro- 
cess then  extends  to  the  cord  and  brain  by  way  of  the  lymph  spaces 
of  the  vessel  sheaths  as  they  enter  the  cord  from  the  meninges.  Here 
similar  hyperemia  and  round-cell  infiltration  take  place  within  the 
perivascular  lymph  spaces. 

This  cellular  infiltration,  extending  along  the  course  of  the  blood- 
vessels, may  partially  constrict  the  lumen  and  cause  extensive  edema. 
A  few  leukocytes  may  be  present  in  the  early  stages,  but  they  are 
replaced  by  lymphocytes,  and  by  glial  and  proliferating  endothelial 
cells.  The  proliferation  and  infiltration  of  cells  extends  into  the 
adjacent  tissues  in  the  tissue  spaces  of  the  cord  and  neuroglia.  In 
addition,  hemorrhages  are  found,  due  either  to  toxic  or  mechanical 
injury  to  the  intima. 

As  a  result  of  these  primary  vascular  changes — cellular  infiltration, 
hemorrhages,  edema — and  the  resulting  anemia,  there  is  degenera- 
tion of  the  interstitial  tissue  and  nerve  cells.  Various  degrees  of 
degeneration  are  observed,  from  simple  swelling  to  complete  destruc- 
tion and  disintegration,  and  after  this  destruction  polymorphonuclear 
neurophages  enter  and  ingest  the  neurotic  material.  The  lumbo- 
sacral and  cervical  enlargements  of  the  cord  are  the  portions  most 
frequently  involved. 


ACUTE  ANTERIOR  POLIOMYELITIS— INFANTILE  PARALYSIS     787 

At  the  same  time  similar  changes  are  observed  in  the  posterior 
roots,  and  to  a  less  extent  within  the  brain,  pons,  and  medulla,  espec- 
ially about  the  cranial  nerve  nuclei,  and  in  the  gray  matter  about  the 
fourth  ventricle. 

A  microscopic  cross-section  made  at  this  acute  stage  shows  hyper- 
emia, especially  about  the  anterior  horn,  increase  in  and  dilatation 
of  the  bloodvessels,  hemorrhages,  cellular  infiltration  of  the  vessel 
walls  and  throughout  the  gray  and  white  matter,  and  nerve  cells  in 
different  stages  of  degeneration.  The  ganglion  cells  may  simply  be 
clouded,  or  the  nuclei  may  be  indistinct  or  may  have  fallen  out,  or 
there  may  be  complete  disintegration  of  the  cells  together  with  its 
dendrites  and  axis-cylinder. 

In  addition  to  these  acute  changes  within  the  central  nervous 
system,  there  is  also  enlargement  of  all  lymphoid  tissue,  especially  of 
Peyer's  patches  in  the  intestines  and  of  the  mesenteric  lymph  glands, 
with  cloudy  swelling  of  all  parenchymatous  organs,  such  as  the  liver 
and  kidneys. 

Should  the  inflammation  subside  when  but  slight  degenerative 
changes  have  taken  place  in  the  nerve  cells,  complete  regeneration 
may  follow;  but,  if  continued  until  there  is  absolute  atrophy,  regen- 
eration is  no  longer  possible,  and  in  consequence  of  the  atrophy  of 
the  cells  and  neuroglia  there  is  a  contraction  of  the  area  about  the 
anterior  horn  which  is  readily  disinguished  on  cross-section.  The 
ganglion  cells  have  disappeared,  and  are  replaced  by  paler  glial  tissue; 
the  vessel  walls  are  thickened;  the  division  between  gray  and  white 
matter  is  indistinct;  and  the  anterior  roots  and  peripheral  nerves 
contain  degenerated  fibers.  The  affected  muscles  exhibit  different 
degrees  of  atrophy,  varying  in  color  from  salmon  to  a  pinkish,  grayish, 
or  yellowish  hue. 

In  extreme  cases  the  muscle  fibers  have  completely  disappeared, 
and  are  replaced  by  fibrous  and  adipose  tissue.  The  long  bones  are 
likewise  aftected,  in  that  they  are  usually  shorter,  and  the  shafts  are 
thinner  than  the  normal  ones.  The  affected  joints  and  ligaments 
are  relaxed.  The  demonstration  of  such  a  widespread  reaction  to 
the  virus  is  wholly  in  line  with  recent  clinical  and  epidemiological 
investigations  which  tend  to  regard  the  disease  as  a  general  infection 
and  a  generalized  process  which  affect  the  parenchymatous  organs, 
the  lymphoid  tissue,  and,  more  especially,  the  nervous  system 
(Peabody,  Draper,  Dochez.) 

Symptomatology. — The  clinical  course  of  poliomyelitis  resembles 
that  of  any  other  acute  infection.  We  distinguish  four  periods:  (1) 
A  period  of  incubation;  (2)  a  period  of  prodromal  and  initial  symp- 
toms;- (3)  a  period  of  paralysis;  (4)  a  period  of  retrogression. 
Frequently  the  different  periods  are  not  separable. 

Incubation. — The  incubation  period  usually  lasts  from  two  to  ten 
days,  although  it  may  be  less  than  twenty-four  hours,  or  may  extend 
to  three  weeks,  according  to  the  virulence  of  the  infection  and  the 
resistance  of  the  patient. 


788  THE  NERVOUS  SYSTEM 

The  prodromal  period  is  characterized  by  certain  general  symp- 
toms which  continue  from  one  to  three  days.  Certain  symptoms 
predominate  in  certain  epidemics.  The  disease  sets  in  usually  with 
fever  which  varies  between  102°  and  106°  F.,  and  occasionally  with 
a  chill;  there  are  general  malaise,  nausea,  vomiting,  loss  of  appetite, 
rapid  pulse  and  respirations,  profuse  sweating,  constipation,  and 
retention  or  suppression  of  urine.  There  may  be  weakness  in  one  or 
more  limbs  or  groups  of  muscles,  and  in  addition  drowsiness,  coma 
and  delirium,  but  rarely  convulsions.  Certain  skin  affections — herpes, 
erythema,  and  a  scarlatinal-like  rash — are  sometimes  observed. 
Meningitic  symptoms  may  be  pronounced.  There  is  rigidity  of  the 
neck,  with  irritability  of  the  spinal  column,  severe  pains  in  the  back 
and  extremities,  hyperesthesia,  basilar  headache,  Kernig's  sign,  and 
tremors;  twitchings  and  convulsive  movements  and  prostration  may 
be  marked. 

In  certain  epidemics  gastro-intestinal  symptoms,  expecially  diar- 
rhea, have  predominated,  while  in  others  the  disease  has  set  in  with 
bronchitis,  or  coryza,  or  with  angina  which  simulated  tonsillitis. 

The  fever  may  run  to  104°  or  106°  F.,  exhibiting  slight  mornmg 
remissions,  then  dropping  by  degrees  to  100°  F.  before  the  onset  of 
paralysis;  it  may  reach  normal  several  days  after  paralysis  has  set 
in.  The  pulse  rate  varies  between  120  and  200,  the  respirations 
between  40  and  60. 

In  some  cases  these  prodromal  symptoms  may  be  so  mild  as  to 
be  entirely  overlooked,  the  paralysis  coming  on  overnight  in  a  pre- 
viously healthy  child.  The  diagnosis  of  the  parah-tic  stage  of  the 
disease  is  of  the  greatest  importance;  for,  if  an  early  diagnosis  is  made, 
proper  measures  can  be  instituted  to  prevent  the  spread  of  the  disease, 
and  early  treatment  begun  before  destruction  of  the  nerve  cells  has 
taken  place.  In  addition  to  the  general  symptoms,  the  examination 
of  the  spinal  fluid  is  an  important  aid  to  the  diagnosis.  In  the  prepara- 
l>i:ic  stage  the  fluid  is  under  moderate  pressure,  increased  in  amount, 
clear  or  opalescent  in  color.  There  is  cellular  increase,  of  which  about 
90  per  cent,  are  polymorphonuclear  cells,  also  a  slightly  increased 
or  normal  globulin  reaction,  with  a  normal  reduction  of  Fehling's 
solution.    On  standing,  a  sterile  coagulum_  may  form. 

Paralysis  usually  sets  in  several  days  after  the  onset.  It  may  either 
appear  suddenly — as  overnight — or  develop  more  gradually,  there 
being  first  a  weakness,  paralysis  following  within  several  days.  The 
paralysis  is  usually  diffuse  and  progressive,  extending  from  one  limb 
to  another,  and  reaching  its  maximum  within  several  days  to  one 
week.  Characteristic  of  the  paralysis  is  its  unsystematic  distribu- 
tion, for  all  combinations  of  paralysis  of  the  extremities,  trunk,  and 
cranial  nerves  may  be  found.  The  following  table,  taken  from  the 
work  of  Frauenthal  and  ^Manning,  shows  the  distribution  of  the 
paralysis,  as  recorded  by  Lovett  and  Sheppard  in  1910: 


ACUTE  ANTERIOR  POLIOMYELITIS— INFANTILE  PARALYSIS     789 

Distribution  of  Early  Paralysis. 

Cases. 

One  leg  only 145 

Both  legs 146 

One  arm  only 44 

Both  arms 12 

One  arm  and  leg,  same  side 50 

One  arm  and  leg,  opposite  sides 18 

Both  legs  and  one  arm 32 

Both  arms  and   one  leg 8 

Both  arms  and  both  legs 51 

Ataxia  (transitory) 7 

Back 79 

Abdomen 38 

Neck 13 

Respiration ' 39 

Deglutition 12 

Intercostal 1 

Face  .       .      .      .  ■ 7 

Right  face 31 

Left  face 24 

Strabismus 2 

759 

From  the  above  it  is  evident  that  the  lower  extremities  are  most 
frequently  involved — twice  to  three  times  as  often  as  the  upper 
extremities.  Paralysis  of  the  diaphragm  and  the  muscles  of  the 
abdomen,  back,  and  neck  is  not  rare.  Bulbar  palsies  are  frequently 
observed,  the  facial  and  hypoglossal  forms,  with  resulting  difficulty 
in  deglutition  and  speech,  being  the  most  common.  In  addition, 
there  may  be  ocular  palsies  from  involvement  of  the  abducens  and 
oculomotor  nerves. 

In  certain  cases,  such  as  have  been  described  by  Medin,  bulbar 
palsies  may  be  the  only  ones  to  appear.  With  the  advent  of  these 
palsies,  the  prodromal  symptoms  diminish  in  intensity,  the  tempera- 
ture, pulse  rate,  and  respiration  suddenly  drop,  and  the  gastro-intes- 
tinal  and  bladder  disturbances  improve,  although  retention  of  urine 
may  persist  when  the  lumbar  segment  is  affected.  On  the  other  hand, 
meningeal  symptoms  progress  until  retrogression  sets  in. 

Whereas,  in  the  beginning,  the  paralysis  is  quite  extensive,  by  the 
end  of' the  second  week  it  usually  recedes  and  there  is  return  of  func- 
tion. In  exceptional  cases  this  may  be  complete.  Usually,  cases  of 
more  or  less  extensive  paralysis  recover,  except  for  one  or  more  extrem- 
ities or  groups  of  muscles;  then  again,  there  may  be  no  recovery  from 
the  paralysis.  When  the  paralysis  affects  the  legs,  two  types  are 
distinguished,  the  upper  and  lower  leg  type.  In  the  upper  or  thigh 
type,  the  glutei,  iliacus,  psoas,  and  antero-external  muscles  of  the 
thigh,  especially  the  quadriceps  femoris,  are  involved;  whereas,  in 
the  lower  leg  type,  the  peronei  and  anterior  tibialis  are  usually  the 
ones  affected. 

Likewise  in  the  arm;  instead  of  the  paralysis  being  complete,  two 
types — upper  and  lower  arm  types — are  usually  recognized.  In  the 
upper  arm  type  the  scapular  muscles — ^the  biceps,  deltoid,  and  sup- 


790  THE  NERVOUS  SYSTEM 

inator  longus — are  involved;  whereas,  in  the  lower  arm  type,  all  the 
muscles  below  the  elbow  except  the  supinator  longus  are  affected. 
Complete  and  permanent  paralysis  of  the  four  extremities,  or  of  an 
arm,  of  the  diaphragm,  back,  neck,  and  intercostal  muscles,  is  rare. 

Permanent  paralysis  of  the  abdominal  muscles  is  more  common. 
The  paralysis  is  flaccid,  and  is  quickly  followed  by  a  diminution  in 
the  size  of  the  affected  parts,  with  atrophy  of  the  muscles  unless  the 
paralysis  quickly  recedes.  A  reaction  of  degeneration  soon  follows. 
In  the  beginning  there  is  increased  irritability  to  mechanical  and 
faradic  stimulation,  but  a  loss  of  reflexes  to  faradic  stimulation  of 
both  muscle  and  nerve  rapidly  develops.  The  muscle  responds  to 
galvanic  stimulation  by  a  slow  vermiform  contraction,  and  the  AGO 
CCA.  Muscles  that  respond  to  faradic  stimulation  usually  recover 
either  entirely  or  in  part;  whereas  muscles  which  exhibit  complete 
reaction  of  degeneration  improve  but  little,  and  never  wholly  recover. 

The  deep  reflexes  of  the  involved  area  are  absent,  but  may  return 
when  the  paralysis  recedes.  If  the  cervical  enlargement  be  involved; 
there  may  be  spasticity  of  the  lower  extremities  with  increased  reflexes, 
ankle  and  patellar  clonus,  and  positive  Babinski  and  Oppenheim 
phenomena.  The  skin  reflexes  are  either  present  or  absent  over  the 
involved  areas.  Hyperesthesia  is  frequently  apparent  at  the  onset; 
otherwise,  there  is  generally  neither  sensory  nor  sphincter  disturb- 
ance. This  period  may  continue  for  several  days  or  several  weeks; 
as  a  rule,  improvement  follows.  Death  may  result,  however,  from 
some  intercurrent  infection  or  from  paralysis  of  the  respiratory  centre. 

When  the  paralysis  does  not  recede,  atrophy  can  be  seen  at  the  end 
of  the  first  week,  and  within  six  to  nine  months  the  affected  part 
may  be  mere-  skin  and  bone.  In  some  cases  the  atrophy  is  replaced 
by  fatty  tissue.  Muscles  which  regain  their  function  even  as  late  as 
the  sixth  to  the  ninth  month  show  much  less  atrophy.  The  reaction 
of  degeneration  goes  hand  in  hand  with  the  paralysis.  Improvement, 
which  is  usually  marked  in  the  first  few  weeks,  may  progress  throughout 
the  first  year,  after  which  time  the  paralysis  is  generally  permanent. 

Trophic  disturbances  of  the  skin,  tendons,  bones,  and  joints  are 
common.  The  skin  of  the  affected  limb  is  cold  and  cyanotic;  the 
paralyzed  limb  inhibited  in  growth.  The  atrophy  of  the  long  bones, 
as  well  as  that  of  the  pelvis,  thorax,  and  spinal  vertebrse  may  be 
detected  by  the  x-rays.  The  tendons  atrophy  from  disuse.  When  the 
muscles  about  a  joint  are  involved,  the  joint  becomes  relaxed  from 
overstretching  of  the  ligaments  and  capsule,  and  results  in  a  looseness 
of  the  joint  which  may  go  on  to  dislocation. 

Owing  to  the  paralysis,  secondary  contractures  develop  early  in 
the  course  of  the  disease,  but  are  usually  not  complete  until  about 
a  year  and  a  half  after  the  onset.  These  contractures  are  due  partially 
to  a  loss  of  tone  in  the  paralyzed  muscles,  but  also  to  a  predominance 
of   the   antagonists. 

If  paralysis  of  an  extremity  is  complete,  the  paralysis  will  be  a 
completely  flaccid  one.     The  most  frequent  deformities  are  those  of 


ACUTE  ANTERIOR  POLIOMYELITIS— INFANTILE  PARALYSIS     791 

the  foot — either  pes  equino  varus,  pes  valgus,  or  pes  planus.  In 
addition  there  may  be  a  claw-hand  {main  en  griff e),  scoliosis,  lordosis 
or  thoracic  asymmetry. 

In  addition  to  the  ordinary  form  of  poliomyelitis,  the  bulbospinal, 
which  is  an  involvement  of  the  lower  motor  segment,  there  are 
two  other  forms  which  need  description: 

1.  The  cerebral  type,  associated  with  a  lesion  of  the  upper  motor 
segment. 

2.  The  abortive  type. 

Cerebral  Tyjje. — Associated  with  the  bulbospinal  type  of  polio- 
myelitis are  rare  cases  of  spastic  paraplegia  with  increased  reflexes 
and  no  atrophy,  but  accompanied  by  tremor,  acute  ataxia,  athetosis, 
and  clouded  mentality,  due  to  involvement  of  the  upper  motor 
segment,  either  of  the  motor  cortex  or  of  the  conduction  paths.  Both 
the  bulbospinal  and  cerebral  types  have  been  observed  in  the  same 
individual  as  w^ell  as  in  several  members  of  the  same  family. 

Abortive  Type. — The  abortive  type  of  poliomyelitis  was  first 
described  by  Wickmann.  It  is  characterized  by  the  usual  prodromal 
symptoms.  Paralysis  does  not  develop,  but  in  some  cases  there 
is  muscular  weakness  with  a  corresponding  diminution  of  reflexes. 
Recovery  is  rapid.  This  is  a  common  form  of  the  disease,  represent- 
ing from  35  to  50  per  cent,  of  all  the  cases.  As  this  type  is  equally 
as  contagious  as  the  paralytic  type,  an  accurate  diagnosis  is  of  the 
utmost  importance;  and,  in  addition  to  the  symptoms,  the  clinical 
laboratory  furnishes  valuable  assistance  in  establishing  the  diagnosis 
from  the  following  points:  (1)  The  spinal  fluid  shows  a  cellular  increase 
with  a  predominance  of  lymphocytes  and  an  increase  of  globulin; 
(2)  the  patient's  blood  serum  has  the  power  of  neutralizing  active 
virus,  making  it  inactive  when  injected  into  monkeys;  (3)  the  virus 
detected  in  the  upper  respiratory  passages  will  communicate  the 
disease  to  monkeys.  The  two  latter  tests  are  as  yet  more  or  less 
impracticable  to  those  who  do  not  have  access  to  an  experimental 
laboratory. 

Diagnosis. — The  diagnosis  of  poliomyelitis  is  usually  made  without 
difflculty  from  the  facts  that  its  onset  is  acute,  that  the  character- 
istic prodromal  symptoms  reach  their  greatest  intensity  within  a 
few  days,  and  that  there  is  a  flaccid  atrophic  paralysis,  with  absence 
of  sensory,  bladder,  or  rectal  disturbances.  The  diagnosis  in  the 
preparalytic  stage,  now  of  the  greatest  importance,  is  usually  not 
difficult  during  epidemics;  but,  owing  to  the  various  aspects  of  the 
symptoms,  may  be  less  readily  made  at  other  times.  For  instance, 
forms  of  the  disease  which  exhibit  marked  meningeal  symptoms  have 
been  confounded  with  cerebrospinal,  tubercular,  or  suppurative 
meningitis,  and  with  meningismus  from  other  acute  infections.  The 
characteristic  findings  in  spinal  fluid  examination,  in  conjunction 
with  the  clinical  symptoms,  will  usually  differentiate  the  types. 

In  poliomyelitis  the  spinal  fluid  is  under  increased  pressure,  clear 
at  the  onset,   becomes  slightly  opalescent  during  the  preparalytic 


792 


THE  NERVOUS  SYSTEM 


stage,  and  again  clears  at  the  height  of  the  paralysis.  During  the 
preparalytic  stage  there  is  a  predominance  of  polymorphonuclear 
cells,    quickly   changing   to   a   predominance   of   lymphocytes   when 

paralysis  appears.  There  is  also 
an  increase  of  globulin,  and  the 
fluid  reduces  Fehling's  solution. 

Such  diseases  as  tuberculosis  of 
the  hip-joint,  osteomyelitis,  rick- 
ets, scurvy,  syphilitic  pseudo- 
paralysis. Parrot's  disease,  and 
syphilitic  epiphysitis,  accompanied 
by  fever  and  pain  in  an  extremity, 
may  at  times  be  confounded  with 
poliomyelitis;  but  careful  exam- 
ination will  usually  reveal  their 
true  nature.  Occasionally  polio- 
myelitis must  be  differentiated 
from  transverse  myelitis  and 
peripheral  neuritis.  Transverse 
myelitis  is  rare  in  childhood;  it 
is  accompanied  by  anesthesia, 
sphincter  involvement,  decubital 
ulcers,  and  spastic  paralysis,  all 
of  which  are  absent  in  polio- 
myelitis. Peripheral  neuritis,  with 
the  exception  of  the  diphtheritic 
form,  is  rare  in  childhood.  Its  de- 
velopment is  slower,  usually  step 
by  step,  the  paralysis  is  more 
symmetrical,  and  is  accompanied 
by  sensory  disturbances. 

Acute  cerebral  palsies  are  dis- 
tinguished by  the  hypertonia 
present,  the  increased  reflexes, 
the  absence  of  a  reaction  of  de- 
generation, convulsions,  athetoid 
movements,  and  involvement  of 
the  intellect. 

Birth  palsies  with  flaccid  par- 
alysis, usually  involving  an  arm 
and  present  at  birth,  may  at  times  be  confounded  with  poliomyelitis. 
Myotonia  congenita  may  be  distinguished  by  the  absence  of  muscular 
atrophy  and  the  absence  of  a  reaction  of  degeneration.  Hysterical 
monoplegias  may  exhibit  atrophy,  but  the  electrical  reactions  are 
normal. 

Prognosis. — The  death  rate  of  epidemic  poliomyelitis,  variously 
estimated  according  to  age  and  area  of  involvement,  is  between  15 
and  24  per  cent.     In  early  infancy,  adolescence,  and  adult  life  the 


Fig.  79. — Patient  five  years,  four 
months  old;  had  anterior  poKomyelitis 
at  the  age  of  twenty-three  months; 
shows  wasting  and  shortening  of  right 
leg. 


ACUTE  ANTERIOR  POLIOMYELITIS— INFANTILE  PARALYSIS     793 

mortality  is  greater  than  in  early  childhood.  As  the  area  of  cord 
involvement  becomes  more  extensive,  and  bulbar  symptoms  develop 
from  involvement  of  the  respiratory  centre,  the  prognosis  becomes 
more  grave.  In  fatal  cases,  death  usually  takes  place  within  eight 
days  following  the  onset,  and  children  should  not  be  declared  out 
of  danger  before  that  time.  The  prognosis  in  the  various  stages — 
the  preparalytic,  progressive,  and  retrogressive — can  be  made  by 
examination  of  the  spinal  fluid,  which,  as  has  been  stated,  is  clear 
at  the  onset,  opalescent  in  the  preparalytic  stage,  and  clears  at  the 
height  of  the  paralytic  stage. 

In  regard  to  the  paralysis,  spontaneous  recoveries  are  frequent 
in  the  mild  paralytic  cases,  being  estimated  by  Frauenthal  and  Man- 
ning at  16  per  cent.,  and  by  Zappert  at  13.7  per  cent.  In  about  80 
per  cent,  of  the  cases,  improvement  takes  place  up  to  a  certain  point, 
and  then  the  paralysis  remains  stationary.  Under  proper  treatment, 
however,  further  improvement  may  take  place  in  cases  which  have 
remained  stationary  for  a  considerable  period;  for  partial  recovery, 
together  with  return  of  response  to  faradic  stimulation,  has  been 
recorded  in  muscles  paralyzed  for  one  to  one  and  one-half  years. 
After  this  period  improvement  is  rare  because  of  the  contractures 
which  have  occurred  by  this  time. 

Prophylaxis. — Since  all  evidence  favors  the  personal  communica- 
tion of  the  disease,  measures  adopted  to  prevent  the  spread  of  con- 
tagion should  be  carried  out  along  these  lines.  A  rigid  quarantine 
should  be  established,  and  last  from  four  to  eight  weeks.  Children 
who  have  been  exposed  should  also  be  isolated,  and  kept  from  other 
children,  churches,  schools,  and  public  gatherings.  For  a  short  time 
urotropin  should  be  administered.  As  the  virus  is  excreted  in  the 
nasopharyngeal  secretions,  all  of  these  should  be  disinfected  and 
prevented  from  drying,  since  desiccation  does  not  destroy  the  virus. 
In  addition  to  the  ordinary  methods,  a  nasal  spray  of  0.5  per  cent, 
of  menthol,  and  a  mouth  wash  of  1  per  cent,  of  hydrogen  peroxide 
should  be  used  for  several  days.  The  urine,  feces,  clothing,  and  all 
linens  used  should  be  carefully  disinfected.  The  attending  physician 
and  nurse  should  likewise  take  the  utmost  precautions  to  prevent 
the  spread  of  the  disease. 

In  addition  there  are  also  chronic  carriers  of  the  disease  who  are 
healthy,  which  further  complicates  the  problem  of  prophylaxis. 
Healthy  carriers  are  those  who  have  come  into  intimate  contact  with 
a  patient;  as,  for  instance,  the  parents. 

Treatment. — During  the  acute  stage,  and  immediately  after  the 
diagnosis  has  been  made,  treatment  should  be  begun.  There  should 
be  absolute  rest  in  bed  in  a  comfortable  position.  An  attempt  should 
be  made  to  eliminate  the  toxins  from  the  body;  (1)  by  forcing  the 
drinking  of  water;  (2)  by  an  initial  cathartic  of  calomel  followed  by 
magnesia;  (3)  by  repeated  colonic  irrigations  and  gastric  lavage; 
(4)  by  hot  packs,  or  hot  air,  and  electric  baths.  For  the  pain  hot 
baths  should  be  given  for  fifteen  minutes,  at  a  temperature  varjdng 


794  THE  NERVOUS  SYSTEM 

between  100°  and  103°  F.,  the  temperature  being  gradually  increased 
several  degrees.  An  ice-bag  should  be  applied  to  the  head  and  spine, 
and  the  temperature  controlled  by  cold  sponging.  All  forms  of 
counter-irritation  are  strongly  contraindicated,  as  is  also  the  use  of 
antipyrin  and  ergot  which  were  formerly  resorted  to. 

Uro tropin,  2  grains,  every  three  hours,  may  be  given  for  four  or 
five  days,  as  well  as  quinine  sulphate  for  its  marked  antiseptic  prop- 
erties. Frauenthal  advocates  the  use  of  tincture  of  echinacea,  5 
minims  to  1  dram  every  six  hours,  as  an  internal  antiseptic. 

Pain,  either  spontaneous  or  from  passive  motion,  is  an  annoying 
symptom  in  this  early  stage,  and  demands  treatment.  Simple 
methods,  such  as  removing  the  weight  of  the  bed  clothes  from  the 
affected  limb,  splinting,  hot  water  or  hot  sand-bags,  an  electrical  pad, 
or  wrapping  the  limb  in  cotton-wool  or  blankets,  will  usually  give 
relief.  When  these  methods  fail,  lumbar  puncture  is  often  beneficial, 
and  sodium  bromide,  grains  5,  may  be  given  to  young  children.  In 
older  patients,  aspirin,  codeine,  phenacetin,  and,  occasionally,  morphine 
may  be  necessary. 

After  the  acute  stage  has  subsided  and  retrogression  has  set  in, 
we  should  aim  to  preserve  the  nutrition  and  function  of  the  paralyzed 
limbs  and  prevent  contractures  by  the  use  of  massage,  electricity, 
and  hydrotherapy. 

Careful  massage,  twice  daily,  should  be  begun  as  soon  as  the  pain 
has  subsided,  and  passive  movements  at  the  same  time  instituted. 
As  soon  as  voluntary  motion  returns  in  the  slightest  degree,  active 
reeducation  movements  should  be  taught.  Passive  movements  can 
be  carried  out  during  the  giving  of  hot  baths.  Active  movements 
should  be  encouraged  as  much  as  possible. 

Electrical  treatment  should  be  begun  early,  as  it  is  the  most 
valuable  form  of  treatment.  Frauenthal  advises  the  use  of  the  sinus- 
oidal current,  alternating  every  second  day  with  a  combined  galvanic 
and  faradic  current.  He  recommends  that  the  electrodes  be  placed 
over  the  origin  and  the  insertion  of  the  muscles.  In  the  beginning 
the  current  must  be  mild,  and  gradually  increased  in  strength;  it 
should  be   kept  up   indefinitely,   as   it  prevents   muscular  atrophy. 

Since  contractures  develop  early  in  the  course  of  the  disease,  they 
should  be  guarded  against  during  the  acute  stage  by  the  use  of  sand 
bags  or  splints  loosely  applied  so  as  not  to  interfere  with  any  motion 
or  nutrition  of  the  extremity.  When  no  deformity  exists,  a  supportive 
apparatus,  such  as  a  walking  chair,  should  be  used. 

In  the  chronic  stage  with  loose  joints,  an  apparatus  should  be 
employed  to  fix  the  joints,  as  well  as  mechanical  appliances  for  the 
contractures.  In  addition  to  numerous  useful  mechanical  appliances 
there  are  certain  surgical  procedures  which  should  always  be  con- 
sidered, such  as  shortening  and  lengthening  of  the  tendons,  trans- 
plantation of  tendons  and  muscles,  insertion  of  artificial  tendons  and 
ligaments,  joint  stiffening,  and,  finally,  nerve  transplantation  and 
nerve   grafting. 


PROGRESSIVE  MUSCULAR  ATROPHY  795 

PROGRESSIVE   MUSCULAR    ATROPHY. 

Formerly  two  distinct  groups  of  muscle  atrophy  were  distinguished; 
namely,  the  spinal,  or  neurogenous  type,  and  the  myogenous  type,  or 
muscular  dystrophy. 

This  simple  classification  sufficed  but  a  short  time,  for  clinicians 
such  as  Charcot,  Marie,  Tooth,  and  Hoffman  observed  cases  which 
maintain  an  intermediary  and  transitional  position  between  these 
two  forms,  exhibiting  symptoms  of  both  types.  At  the  present  time 
we  distinguish  in  children  the  following  forms: 
I.    Progressive  muscular  atrophy. 

A.  Early    infantile    spinal    progressive    muscular    atrophy 

(Werdnig,  Hoffman). 

B.  Progressive     muscular     atrophy,     adult     t}^e     (Aran, 

Duchenne) . 

C.  Amyotrophic  lateral  sclerosis. 

n.  Neural   Form   of   Progressive   Muscular   Atrophy    (Charcot, 

Marie,  Tooth,  Hoffman),. 
HI.  Muscular  Dystrophy. 

Early  Infantile  Spinal  Progressive  Muscular  Atrophy  (Werdnig, 
Hoffman). — This  type  of  progressive  muscular  atrophy  was  disco verd 
by  Werdnig  in  1891,  and  reported  by  Hoffman  in  1893.  It  is  essen- 
tially a  family  disease,  several  members  of  a  family  being  usually 
affected.  It  is  rarely  hereditary,  although  Hoffman  observed  it  in 
several  generations  of  one  family.  Isolated  cases  have  been  described. 
It  is  a  very  rare  disease,  as  only  30  cases  have  been  collected  from 
the  literature. 

Pathological  Anatomy. — There  is  degeneration  of  the  anterior  horn 
cells,  motor  roots,  and  nerves,  with  resulting  marked  atrophy  of 
muscles;  sometimes  there  is  secondary  fatty  degeneration  of  muscle 
fibers, — lipomatosis  inter stitialis. 

Prognosis. — The  course  is  a  rapid  and  progressive  one,  death  usually 
taking  place  within  one  to  four  years  either  from  paralysis  of  respira- 
tion or  some  intercurrent  infection. 

Symptomatology. — The  disease  is  one  of  early  childhood,  usually 
appearing  within  the  first  year  of  life,  and  affecting  hitherto  healthy 
children.  It  is  characterized  by  progressive  weakness,  which  affects 
both  sides  symmetrically,  first  appearing  in  the  proximal  group  of 
muscles.  The  muscles  about  the  pelvis  and  thigh,  the  glutei,  ilio- 
psoas, and  quadriceps  femori^,  are  first  involved,  then  it  extends 
upward  and  involves  the  muscles  of  the  back,  neck,  shoulder-girdle, 
and  upper  arm — the  deltoid,  serrati,  rhomboids,  supraspinalis  and 
infraspinatus,  the  biceps  and  triceps.  Finally,  as  the  disease  pro- 
gresses, the  muscles  of  the  forearm,  the  legs,  and  the  smaller  muscles 
of  the  hands  and  feet  are  attacked.  The  muscles  of  the  calf  are  affected 
late  in  the  disease.  Even  in  well  advanced  cases  the  distal  muscles 
of  the  extremities  are  but  little  involved. 

Paralysis    and    atrophy    of   the    affected   muscles   quickly   follow. 


796  THE  NERVOUS  SYSTEM 

Atrophy  about  the  calves  and  glutei  is  frequently  masked  by  an 
excessive  deposition  of  fat  between  the  degenerated  muscle  fibers, 
the  so-called  pseudohypertrophy.  Deformities  of  the  body,  hands, 
and  feet  are  observed,  and  extreme  scoliosis  may  be  present.  There 
is  talipes  equinus  varus;  the  fingers  and  toes  may  be  claw-shaped 
{main  en  griff e).  Fibrillary  twitchings  are  variable.  There  are  no 
sensory  disturbances.  The  deep  reflexes  are  absent,  the  plantar 
response  is  normal.  Electrical  changes — that  is,  either  partial  or 
complete  reaction  of  degeneration — are  demonstrable.  The  cranial 
nerves  usually  escape.  All  organs  of  sense,  speech  development, 
intelligence,  and  sphincter  control,  remain  unaffected. 


Fig.  80. — Progressive  muscular  atrophy  {main  en  griffe). 

Diagnosis. — In  cases  exhibiting  the  characteristic  symptoms  and 
course,  the  diagnosis  is  easy.  The  disease  may  sometimes  be  con- 
founded with  the  neural  form  of  muscular  atrophies,  the  myopathies, 
poliomyelitis,   and  myotonia  congenita    (Oppenheim). 

Treatment. — No  known  treatment  influences  the  course  of  the 
disease. 

Progressive  Muscular  Atrophy,  Adult  Form  (Aran,  Duchenne)  .—This 
form  rarely  occurs  except  in  older  children,  but  when  observed  it  is 
the  same  as  in  the  adult.  The  feature  which  most  clearly  distinguishes 
it  from  the  usual  form  in  children  is  that,  in  this  adult  type,  heredity 
plays  no  role,  also  that  the  disease  usually  begins  in  the  distal  portion 
of  the  extremities  about  the  small  muscles  of  the  hands  and  feet. 

Amyotrophic  Lateral  Sclerosis  (Charcot). — This  form  rarely  occurs 
in  children,  and  its  existence  was  even  denied  until  Keehn  and  Naif 
demonstrated  it  pathologically.  It  is  a  hereditary  family  disease, 
but  isolated  cases  have  been  observed.  The  age  of  onset  varies  from 
early  childhood  to  puberty. 


NEURAL  FORM  OF  PROGRESSIVE  MUSCULAR  ATROPHY      797 

Pathological  Anatomy, — Among  the  findings  is  sclerosis  of  the  lateral 
tracts  of  the  cord,  involving  the  direct  p^Tamidal  and  Gower's  tracts, 
together  with  atrophy  of  the  anterior  horn  cells  and  the  nuclei  of 
the   medulla. 

Symptomatology. — The  disease  sets  in  with  weakness  in  the  muscles 
of  the  extremities,  and  difficulty  in  walking,  the  legs  being  stiff,  and 
the  child  compelled  to  walk  upon  its  toes.  Other  cases  begin  with 
bulbar  symptoms — difficulty  in  chewing,  swallowing,  and  speaking. 
Contractures  of  the  arms  and  legs  develop  early.  The  deep  reflexes 
are  greatly  exaggerated.  Oppenheim  and  Babinski  phenomena  and 
both  ankle  and  patellar  clonus  are  present.  At  the  same  time  there 
is  atrophy  of  the  small  muscles  of  the  hands.  The  reaction  of  degen- 
eration is  obtained  in  the  affected  muscles,  and  there  are  fibrillary 
twitchings,  but  no  sensory,  sphincter,  or  pupillary  changes.  Mental 
development  is  frequently  defective. 

Course. — ^The  course  of  the  disease  is  usually  rapid  and  progressive; 
although  it  may  remain  stationary  for  a  time,  it  is  always  fatal. 

Diagnosis. — Progressive  muscular  atrophy  in  the  adult  must  be 
difi^erentiated  from  spastic  paraplegia  and  diphtheritic  paralysis. 
The  combination  of  flaccid  and  spastic  symptoms  tends  to  clear 
the  diagnosis. 

Treatment. — ^Any  treatment  is  unsatisfactory.  Systematic  massage 
and  warm  baths  should  be  tried.     Electricity  benefits  but  little. 

THE    NEURAL    FORM    OF    PROGRESSIVE   MUSCULAR    ATROPHY, 

PERONEAL  TYPE. 

(Charcot,  Marie,  Tooth,  Hoffman.) 

This  type  was  described  by  Eulenburg  in  1856,  by  Charcot  and 
Marie  in  1886,  and  in  the  same  year  by  Tooth.  Later,  in  1S89,  it 
was  also  described  by  Hoffman. 

Etiology. — It  is  essentially  a  hereditary  family  disease,  observed 
in  some  cases  through  four  or  five  successive  generations.  Boys  are 
affected  more  frequently  than  girls.  The  age  of  onset  usually  extends 
from  early  childhood  to  adolescence. 

Pathological  Anatomy. — There  are  spinal  and  peripheral  changes. 
There  are  degenerative  changes  in  the  posterior  columns  of  the  cord, 
in  some  of  the  anterior  horn  cells,  in  the  anterior  and  posterior  roots, 
and  in  the  peripheral  nerves. 

Symptomatology. — In  the  neural  form  of  progressive  muscular 
atrophy  the  involvement  of  the  distal  portion  of  the  extremities  is 
characteristic.  Muscular  weakness  and  atrophy  usually  begin  s^tu- 
metrically  in  the  peroneal  group  of  muscles  and  the  smaller  muscles 
of  the  feet,  causing  a  foot-drop  in  walking,  the  so-called  characteristic 
"steppage  gait."  The  muscles  of  the  calf  are  as  yet  well  preserved. 
The  disease  may  remain  stationary  for  from  one  to  four  years,  and 
then  may  extend  to   the  upper  extremities,   involving  the   smaller 


798  THE  NERVOUS  SYSTEM 

muscles  of  the  hands,  the  extensors  of  the  forearm,  and  the  extensors 
of  the  fingers  and  hand.  In  some  cases  the  disease  may  spread  out 
over  the  proximal  portions  of  the  extremities,  involving  the  thigh, 
pelvic  girdle,  the  fore  and  upper  arms,  shoulder-girdle  and  back. 

Pseudomuscular  hypertrophies  are  not  present.  Fibrillary  twitch- 
ings  are  frequently  observed.  The  Achilles  reflex  is  always  absent 
and  the  other  deep  reflexes  are  either  diminished  or  abolished,  depend- 
ing upon  the  amount  of  atrophy.  Sensory  disturbances,  such  as 
pain,  hyperesthesia,  anesthesia,  analgesia,  and  vasomotor  disturb- 
ances, are  common.  Complete  or  partial  reaction  of  degeneration 
is  present.  Diminished  excitability  may  also  be  observed  in  muscles 
apparently  normal.  Sphincter  disturbances  do  not  occur.  Secondary 
contractures  are  common.  Club-foot  (pes  varus),  or  equinovarus,  and 
clawed  hands  and  feet  are  common. 

Prognosis. — The  disease  is  a  slowly  progressive  one,  extending  over 
a  number  of  years.  It  may  be  arrested  at  different  stages,  but  exacer- 
bations occur.     Death  usually  is  due  to  some  intercurrent  infection. 

Diagnosis. — This  form  must  be  differentiated  from  the  other  forms 
of  progressive  muscular  atrophy  and  dystrophy,  and  from  multiple 
neuritis;  but,  when  characteristically  developed,  the  diagnosis  is 
usually  not  difficult. 

Treatment. — The  treatment  is  only  symptomatic.  General  hygienic 
and  dietetic  measures,  massage,  and  galvanism  should  be  employed. 
For  the  contractures,  tenotomy  and  orthopedic  appliances  are 
necessary. 

PROGRESSIVE  MUSCULAR   DYSTROPHY. 

A  characteristic  feature  of  the  myopathies  and  the  dystrophies 
is  that  anatomically  the  primary  affection  appears  in  the  muscles, 
and  that  the  spinal  cord  and  the  peripheral  nerves  escape.  Clinically 
we  distinguish  four  different  t^'pes  of  dystrophy,  as  demonstrated 
by  Erb,  but  they  cannot  always  be  clearly  differentiated.  They  are 
as  follows: 

I.  Pseudohypertrophic  type  (Duchenne). 
II.  Juvenile  type:     Scapulohumeral   (Erb). 
III.  Infantile  type:    Facies-scapulohumeral  (Landouzy,  Dejerine). 
TV.  Simple  atrophic  type:  Hereditary  (Erb,  Leyden,  ]\Ioebius). 

Etiology. — ^This  is  a  true,  endogenous,  hereditary,  family  disease, 
which  may  occur  in  several  members  of  the  same  family  throughout 
several  generations.  It  is  usually  transmitted  through  the  mother, 
she,  herself,  being  rarely  affected.  Trauma,  infections,  and  inan- 
ition may  be  accessory  etiological  factors.  The  age  of  onset  varies 
considerably  in  the  different  varieties;  it  may  occur  at  any  time  from 
early  infancy  to  puberty,  or  may  be  delayed  until  adolescence  has 
set  in. 

Pseudohypertrophic  Type  (Duchenne). — The  usual  age  of  onset  is 
between  two  and  seven  years,  and  the  disease  develops  slowly.  The 
child  may  be  late  in  learning  to  walk.    At  first  there  is  awkwardness 


PROGRESSIVE  MUSCULAR  DYSTROPHY 


799 


in  gait,  also  muscular  weakness  which  is  shown  by  the  ease  with  which 
the  child  falls,  and  by  the  difficulty  in  rising.  This  type  is  character- 
ized by  atrophy  and  hypertrophy  of  the  proximal  group  of  muscles, 
with  a  predilection  for  certain  groups;  thus,  the  long  muscles  of  the 
back  or  the  abdominal  muscles  may  be  involved  first.  The  muscles 
about  the  pelvic  girdle  and  thigh,  the  glutei  and  anterior  muscles 
of  the  thigh,  the  adductors,  and  then  the  flexor  cruris,  are  involved. 
Later  the  muscles  of  the  calf,  the  dorsal  flexors  of  the  foot,  and,  as 


Fig.  81. — Pseudohypertrophic  muscular  paralysis.     Boy  is  climbing  up  upon  his  legs. 

the  disease  progresses,  the  muscles  about  the  shoulder-girdle  and 
upper  arm  become  affected.  There  is  also  a  tendency  to  hypertrophy 
of  certain  muscles;  thus,  in  the  lower  extremity  the  gluteus,  sartorius, 
and  muscles  of  the  calf;  in  the  upper  extremity  the  deltoid,  infra- 
spinatus, supraspinatus,  and,  sometimes,  the  triceps  show  beginning 
hypertrophy.  The  distal  portion  of  the  extremities  is  usually  not 
involved.     All  this  forms  a  characteristic  picture. 

Paralysis  of  the  muscles  of  the  back  produces  lordosis  with  prom- 
inent and  protruding  abdomen,  and  compels  the  child  to  throw  its 
shoulders  back  and  also  to  hold  the  head  and  trunk  erect  in  order  to 
maintain  its  equilibrium.  Thus,  a  plumb-line,  dropped  from  the 
scapula,  falls  behind  the  buttocks.  The  child's  power  of  locomotion 
is  greatly  impaired. 

There  is  a  characteristic  waddling  gait,  like  that  of  a  goose,  or  of 
a  child  suffering  from  congenital  hip  disease.    The  trunk  is  swayed 


800 


THE  NERVOUS  SYSTEM 


from  side  to  side  in  order  to  get  the  centre  of  gravity  over  the  hip- 
joints,  and,  also,  because  of  the  difficulty  in  raising  the  thighs. 

The  manner  of  rising  from  the  floor  is  almost  pathognomonic. 
The  child  first  rolls  over  on  his  face  and  abdomen,  draws  his  legs  up 
under  him,  and  extends  his  legs  on  the  thighs.  He  then  brings  his 
hands  near  the  feet,  and,  in  order  to  elevate  the  trunk,  he  climbs  up 
upon  his  legs  with  his  hands;  finally,  by  giving  his  head  a  swing,  the 


Fig.  82. — Pseudohypertrophic  muscular  paralysis,  showing  lordosis  in  the  erect  posture. 


shoulders  are  thrown  back,  and  his  equilibrium  is  attained.  In  addi- 
tion, there  is  diflBculty  in  mounting  stairs. 

Another  characteristic  sign  is  the  loose-winged  scapula.  For 
instance,  if  one  attempts  to  raise  the  child  after  pressing  his  shoulders 
against  his  sides  he  "falls  through"  to  his  ears. 

Certain  contractures  appear.  There  is  a  pes  equinus,  from  contrac- 
tion of  the  muscles  of  the  calf.  Contractures  of  the  elbow-  and  knee- 
joints  also  develop.    The  mentality  is,  as  a  rule,  normally  developed, 


PROGRESSIVE  MUSCULAR  DYSTROPHY  801 

although  a  number  of  cases  have  been  reported  which  were  associated 
with  idiocy  and  epilepsy.  Fibrillary  twitchings  and  the  reaction 
of  degeneration  rarely  occur.  The  deep  reflexes  are  present,  and  the 
plantar  response  and  sensation  are  normal.  There  are  no  sphincter 
disturbances. 

Juvenile  Type,  Scapulohumeral  (Erb). — The  type  described  by 
Erb  begins  late  in  childhood,  and  is  characterized  by  atrophy,  begin- 
ning about  the  shoulder-girdle.  Some  muscles  are  hypertrophied, 
while  others  are  atrophied.  Later,  the  muscles  of  the  upper  arm,  then 
those  of  the  back  (with  resulting  lordosis),  finally  those  about  the 
pelvic  girdle,  the  thigh  and  calf,  and  peronii  muscles  (with  resulting 
talipes  equinus),  are  involved. 

Infantile  Type,  Facies-scapulohumeral  (Landouzy,  Dejerine). — This 
form  begins  within  the  first  few  months  of  life,  affecting  male  and 
female  babies  equally,  and  involving  the  muscles  of  the  face,  espec- 
ially the  sphincters  of  the  eyes  and  mouth.  There  follows  a  lack  of 
facial  expression — a  mask-like  appearance,  with  inability  to  raise 
the  eyebrows,  close  the  eyes,  or  puff  out  the  cheeks.  At  the  same  time 
there  may  be  involvement  of  the  shoulder-girdle,  or  this  may  be  the 
only  symptom  of  the  disease  for  years,  after  which  the  process  may 
extend  to  the  shoulders,  thighs,  and  pelvis. 

Simple  Atrophic  Type,  Hereditary  (Erb,  Leyden,  Moebius) .^— This 
form  exhibits  an  unusual  hereditary  character,  with  no  muscular 
hypertrophy. 

These  different  forms  are  mere  varieties  of  the  disease,  and  all 
possible  combinations  of  them  may  exist  in  the  same  individual. 

Pathological  Anatomy. — The  pathological  changes  are  similar  in 
all  the  forms.  The  changes  are  essentially  primary  in  the  muscles, 
for  none  occur  in  the  central  nervous  system.  There  is  atrophy  of 
most  of  the  muscle  fibers,  with  fatty  degeneration,  fatty  and  connec- 
tive-tissue infiltration  between  the  individual  muscle  fibers,  and  true 
hypertrophy  of  other  muscle  cells.  On  microscopic  section,  the 
striations  of  the  muscle  fibers  have  disappeared,  the  fibers  are  of 
different  sizes,  some  large  and  other  small,  and  they  show  fatty  degen- 
eration, vacuolation,  and  a  contraction  of  the  muscle  fibers.  Outside 
the  sarcolemma  sheath,  there  is  deposited  fat  and  connective  tissue, 
showing  numerous  connective-tissue  nuclei.  The  fat  later  becomes 
absorbed,  and  the  connective  tissue  contracts,  the  atrophied  muscle 
being  finally  replaced  by  contracted  fibrous  tissue.  There  is  also  true 
hypertrophy  of  other  muscle  fibers. 

Diagnosis. — When  fully  developed,  the  diagnosis  of  this  disease 
usually  presents  no  great  difficulty.  It  must  be  differentiated,  how- 
ever, from  the  different  forms  of  muscular  atrophy.  As  these  two  types 
are  the  antitheses  of  one  another,  it  must  be  borne  in  mind  that 
there  are  transitional  forms  which  exhibit  in  part  neiu-ogenic,  in  part 
myogenic  symptoms.  At  times,  syringomyelia,  diphtheritic  paralysis, 
and  beginning  spondylitis  may  be  confounded  with  progressive  mus- 
cular dystrophy. 
51 


802  THE  NERVOUS  SYSTEM 

Prognosis. — The  course  of  the  disease  is  slow  but  progressive,  extend- 
ing over  a  number  of  years  before  the  patient  becomes  bed-ridden 
unless  death  supervenes  as  the  result  of  some  intercurrent  infection. 
The  disease  may  remain  stationary  for  a  number  of  years;  even 
recoveries  from  the  juvenile  type  have  been  reported  by  Erb.  The 
most  unfavorable  forms  are  those  which  begin  in  early  childhood  and 
are  of  the  pseudohypertrophic  t^'pe. 

Treatment. — Xo  treatment  is  effectual.  Organic  extracts  of  the 
th^Toid,  thymus,  and  pituitary  glands  have  been  tried,  also  injections 
of  fibrolysin.  Hygienic  measures,  such  as  fresh  air,  nourishhig  food, 
and  gymnastic  exercises,  with  moderate  massage,  and  electricity, 
especially  galvanism,  to  both  affected  and  unaffected  muscles,  should 
be  prescribed.  Tenotomy  and  tendon  transplantation  may  be  neces- 
sary for  the  contractures,  and  orthopedic  appliances  to  give  support 
to  the  partially  degenerated  muscles. 

MYOTONIA   CONGENITA    (THOMSEN'S    DISEASE). 

This  rare  disease  is  hereditary,  occurs  in  several  members  of  the 
same  family,  and  is  usually  congenital.  Boys  are  more  frequently 
affected  than  girls. 

Pathological  Anatomy. — Schiefferdecker  demonstrated  h^-pertrophy 
of  the  muscle  fibers,  an  increase  in  nuclei  arranged  in  rows,  and 
granulation  of  the  sarcoplasm. 

Symptomatology. — The  chief  s\Txiptom  of  the  disease  is  a  slow 
muscular  contraction  or  myotonic  spasm  when  voluntary  movements 
are  attempted.  This  tonic  spasm  may  last  from  five  seconds  to  half  a 
minute  and  then  relax,  allowing  the  normal  movements  to  be  carried 
out.  Different  groups  of  muscles  may  be  thus  affected;  but  the 
muscles  most  frequently  involved  are  those  of  the  extremities,  the 
legs  more  often  than  the  arms.  Next  in  order  of  frequency  are  the 
trunk  muscles,  finally  those  innervated  by  the  cranial  nerves,  the 
sphincters  of  the  eye,  the  masticators,  the  esophageal,  and  laryngeal 
muscles.  Hence  the  infant  may  have  difficulty  when  it  attempts 
to  nurse,  older  children  on  attempting  to  walk,  the  patient's  feet 
being  glued  to  the  ground,  also  on  shaking  hands,  the  child  not  being 
able  to  let  go  until  relaxation  is  complete.  Fright  and  cold  increase 
the  spasm,  whereas  heat  and  alcohol  relax  it. 

The  disease  is  not  apt  to  be  recognized  in  early  infancy  and  child- 
hood, except  in  familial  cases.  The  general  appearance  of  the  patient 
indicates  a  good  athletic  physique,  although  the  strength  is  subnormal. 

On  examination  we  find  two  characteristic  signs: 

I.  The  muscles  show  an  increased  irritability  to  mechanical 
stimuli.  At  the  point  of  stimulation  there  appears  a  localized  swelling, 
due  to  muscular  contractions,  persisting  from  ten  to  fourteen  seconds, 
and  then  gradually  relaxing. 

H.  There  is  also  increased  irritability  of  the  muscles  to  electrical 
stimuli.    Mild  faradic  cm-rents  induce  a  muscle  spasm,  which  persists 


SYRINGOMYELIA  803 

for  a  number  of  seconds  after  the  current  is  cut  off.  Direct  galvanic 
currents  give  rise  to  a  reaction  similar  to  the  reaction  of  degeneration. 
This  is  Erb's  myotonic  reaction.  There  are  no  sensory  or  sphincter 
disturbances. 

Diagnosis. — The  condition  should  be  differentiated  from  tetany. 

Prognosis. — The  affection  is  not  fatal,  but  persists  through  life. 

Treatment. — ^Massage  and  gymnastic  exercises  should  be  prescribed. 
Organic  extracts  have  been  tried,  but  without  results. 

MYOTONIA   CONGENITA    (OPPENHEIM). 

This  disease  was  described  by  Oppenlieim  in  1900.  As  its  name 
implies,  it  is  congenital,  and  is  usually  observed  in  the  first  few  days 
of  life.  It  is  characterized  by  a  congenital  muscular  weakness,  usually 
a  bilateral  symmetrical  flaccidity,  which  affects  most  frequently  the 
lower  extremities,  less  often  the  upper.  The  children  lie  motionless, 
unable  to  move  their  legs.  Hypotonus  is  extreme,  and  the  limbs 
will  remain  in  any  position  in  which  they  are  placed.  The  neck, 
diaphragm,  and  facial  muscles  usually  escape.  There  is  no  muscular 
atrophy.  The  deep  reflexes — the  knee-jerk  and  i^chilles  reflex — 
are  greatly  diminished  or  absent.  The  electrical  irritability  of  the 
muscles  is  also  diminished  or  absent,  but  the  reaction  of  degeneration 
is  not  observed.  There  are  no  sensory  or  sphincter  disturbances. 
The  mentality  is  normally  developed. 

Pathological  Anatomy. — Partial  degenerative  changes  in  the  anterior 
horn  cells  and  muscle  fibers  have  been  described,  but  these  patho- 
logical changes  are  by  no  means  uniform.  Rothmann  considers  the 
disease  a  form  of  the  early  infantile  type  of  muscular  atrophy 
(Werdnig,  Hoffman). 

Prognosis  and  Treatment., — Recovery  is  possible,  but  the  course 
is  slow,  and  the  majority-  of  the  children  affected  die  from  some  inter- 
current infection.  Systematic  massage  and  electrical  treatment 
should  be  instituted,  and  the  organic  extracts,  especially  thyroidin, 
given  a  trial. 

SYRINGOMYELIA. 

Up  to  the  age  of  puberty  this  disease  is  exceedingly  rare,  even  its 
existence  having  been  disputed.  It  is  closely  related  to  congenital 
malformations  of  the  central  nervous  system,  and  has  been  described 
as  accompanying  hydrocephalus,  spina  bifida,  meningocele,  syringo- 
myelocele, and  reduplication  of  the  cord.  In  some  children  the 
affection  has  an  hereditary  character. 

Pathological  Anatomy. — ^A  cavity  forms  in  the  cord,  being  more 
frequently  due  to  the  disintegration  of  a  previously  formed  mass  of 
gliomatous  cells  which  had  infiltrated  the  normal  tissue.  This  infil- 
tration begins  near  the  central  canal  and,  as  degeneration  progresses, 
the  cavity  invades  the  surrounding  spinal  marrow,  the  posterior 
horns,  posterior  columns,  and  the  anterior  horns.  The  cavity  is  usually 
irregular  in  outline  and  varies  in  size. 


804  THE  NERVOUS  SYSTEM 

Symptomatology. — The  symptoms  of  this  disease  are  essentially 
the  same  as  in  the  adult.  There  is  progressive  muscular  atrophy  of 
the  upper  extremities  from  involvement  of  the  anterior  horn  cells, 
and  an  accompanying  spastic  paraplegia  of  the  lower  limbs  from 
involvement  of  the  pyramidal  tract. 

The  sensory  disturbances  are  very  characteristic.  There  is  loss  of 
pain  sense  and  temperature  sense  on  the  same  side  as  the  lesion,  while 
muscle  sense  and  the  sense  of  touch  may  be  preserved.  In  addition, 
there  are  vasomotor  and  trophic  disturbances  of  the  skin  and  nails, 
hyperemia,  anemia,  bullous  eruptions,  ulcerations,  abscesses,  especially 
upon  the  fingers  (Mowan's  type),  and  arthropathies.  Secondary  con- 
tractures, claw-hand  {main  en  griff e),  and  kyphoscoliosis  are  also 
observed.  The  symptoms  naturally  depend  upon  the  position  and 
extent  of  the  lesion.     Bulbar  symptoms  may  be  present. 

Prognosis  and  Treatment. — The  course  of  the  disease  is  slow  but 
progressive,  and  is  uninfluenced  by  any  known  treatment. 

HEREDITARY  ATAXIA  (FRIEDREICH'S  ATAXIA)— HEREDITARY 
CEREBELLAR    ATAXIA    (MARIE). 

We  distinguish  two  distinct  types  of  hereditary  ataxia:  (1)  the  clas- 
sical spinal  type,  described  by  Friedreich  in  1861 ;  and  (2)  the  cerebellar 
type  described  by  Marie  in  1893,  known  as  hereditary  cerebellar 
ataxia.  Today  these  two  types  are  considered  to  be  merely  two  forms 
of  the  same  disease,  although  clinically  and  anatomically  they  may 
appear  as  distinct  entities;  there  are  also  mixed  and  transitional  forms 
which  clearly  demonstrate  their  relationship. 

Etiology. — Hereditary  ataxia  is  a  family  disease,  often  affecting 
several  members  of  a  family,  and  the  two  sexes  equally;  it  has  also 
been  observed  in  successive  generations  of  a  family.  Sporadic  cases, 
however,  occur  quite  frequently.  It  appears  early  in  life,  most  com- 
monly between  four'  and  seven  years  of  age,  although  it  may  begin 
much  later,  even  at  thirty.  The  cerebellar  type  (Marie)  usually  sets 
in  later  in  hfe,  at  about  twenty  years  of  age,  yet  may  begin  in  early 
childhood.  There  is  a  history  of  alcoholism,  syphilis,  epilepsy,  or 
insanity  in  the  parents.  Not  infrequently  it  follows  certain  infectious 
diseases. 

Pathological  Anatomy. — Either  the  spinal  cord  or  cerebellum,  or 
both,  depending  upon  the  form,  whether  spinal,  cerebellar,  or  mixed, 
are  diminished  in  size  and  show  degenerative  changes. 

Of  the  degenerative  changes  in  the  cord  there  is  sclerosis,  which 
involves:  (1)  The  posterior  columns — the  column  of  Goll  com- 
pletely, and  the  column  of  Burdoch  only  partially;  (2)  the  lateral 
columns — degeneration  of  the  ganglion  cells  of  Clark's  column,  of 
the  direct  cerebellar  tract,  of  Gowers's  tract,  and  the  crossed  pjnramidal 
tract  in  the  lumbar  region;  (3)  at  times  the  anterior  columns  of  the 
cord.  In  the  cerebellum  there  are  degenerative  changes  in  the 
Perkinje  cells  of  the  cortex  and  of  the  cerebellar  nuclei. 


HEREDITARY  ATAXIA  805 

Spinal  Form:  Symptoms. — The  most  characteristic  symptom  is 
locomotor  ataxia,  beginning  in  the  lower  extremities.  The  child 
walks  with  its  legs  widely  separated,  taking  small  steps,  and  sway- 
ing to-and-fro  like  a  drunken  man.  Ataxia  of  the  upper  extremities 
sets  in  later,  frequently  associated  with  a  simple  or  an  intention 
tremor  which  involves  the  entire  body,  especially  the  head  and  shoul- 
ders, causing  a  wobbling  of  the  head  and  shoulders  or  whole  body; 
in  addition,  there  are  at  times  choreic  or  athetoid  movements.  Static 
ataxia  is  frequently  present;  i.  e.,  ataxia  of  the  body  when  standing 
erect  or  on  extending  a  limb.  A  true  Romberg  sign  does  not  usually 
appear. 

Sensory  disturbances  are  generally  lacking.  The  deep  reflexes 
are  diminished  or  abolished,  although  the  Babinski  phenomenon 
may  often  be  present.  The  other  skin  reflexes  are  normal.  The 
sphincters  usually  escape. 

Nystagmus  is  a  characteristic  symptom.  The  pupillary  reactions 
are  normal,  and  optic  nerve  atrophy  and  ocular  palsies  rarely  occur. 
Speech  disturbances  are  common,  the  speech  being  slow,  awkward, 
and  at  times  scanning. 

Deformities  are  the  rule.  Scoliosis  is  frequently  observed.  The 
deformity  of  the  foot  is  characteristic.  There  is  talipes  equinovarus, 
with  the  dorsum  bowed,  the  big  toe  flexed  dorsally,  and  the  remaining 
toes  assuming  a  claw-like  appearance.  A  claw-hand  {main  en  griffe) 
is  also  observed  at  times.  These  contractures  are  secondary  to 
muscular  atrophy.  Trophic  changes  do  not  occur.  The  intelligence 
is  normal. 

The  cerebellar  type  (Marie)  differs  in  that  it  usually  begins  after 
puberty.  The  ataxia  is  of  the  cerebellar  type.  Optic  nerve  atrophy 
and  ocular  palsies  are  quite  frequent,  and  the  deep  reflexes  are  exag- 
gerated. Sensory  disturbances  are  common.  Between  these  two  types 
numerous  transitional  forms  have  been  described,  with  one  or  the 
other  type  predominating. 

DiflEerential  Diagnosis. — The  disease  must  be  differentiated  from 
multiple  sclerosis,  cerebellar  tumor,  juvenile  tabes,  and  cerebral 
syphilis.  Multiple  sclerosis  is  very  rare  in  early  childhood,  and  in 
this  affection  nystagmus  and  intention  tremor  are  generally  more 
marked.  From  cerebellar  tumor  it  can  be  distinguished  by  the  absence 
of  the  general  symptoms  of  brain  tumor — headache,  vomiting,  optic 
neuritis — and  by  its  more  chronic  course.  From  multiple  neiu'itis 
it  can  be  differentiated  by  the  history.     Juvenile  tabes  is  very  rare. 

It  is  characterized  by  lightning  pains,  headache,  crises,  pupillary 
changes,  optic  atrophy,  and  bladder  disturbances.  From  cerebral 
syphilis  or  juvenile  tabes  Friedreich's  ataxia  is  distinguished  by  the 
absence  of  a  positive  Wassermann  reaction,  both  in  the  blood  serum 
and  spinal  fluid,  and  by  an  entirely  negative  spinal  fluid. 

Prognosis.— The  course  of  the  disease  is  slow  and  progressive,  but 
several  years  may  elapse  before  the  patient  is  bed-ridden.  It  may 
be  arrested  for  a  time,  and  may  extend  over  a  period  of  thirty  years. 


806  THE  NERVOUS  SYSTEM 

but  is  incurable.  Death  usually  results  from  some  intercurrent 
affection. 

Treatment. — No  drugs  have  any  influence  upon  the  course  of  the 
disease.  These  patients  should  have  plenty  of  fresh  air,  sunshine, 
and  good  nourishing  food.  ■Massage  and  Frenkel's  reeducation 
movements  should  be  employed.  When  the  patient  is  bed-ridden, 
care  must  be  taken  to  prevent  contractures. 

TUMORS    OF    THE    SPINAL   CORD. 

Tumors  of  the  cord  are  rare  in  childhood,  but  two  main  types 
may  be  distinguished: 

1.  Extramedullary  tumors,  arising  from  the  spinal  meninges,  of 
which  we  may  further  differentiate  two  \'arieties — the  extradural  and 
intradiu-al. 

2.  Intramedullary  tumors  which  form  within  the  spinal  marrow. 
Extramedullary  tumors  are  the  more  common,  and  among  these 

are  sarcoma,  myxosarcoma,  angiosarcoma,  endothelioma,  syphiloma, 
miliary  tubercle,  fibroma,  mixed  tumors,  and,  in  infancy  especially, 
associated  with  congenital  malformations  of  the  cord,  also  lipoma 
and  teratoma.  Of  the  intramedullary  variety,  there  are  solitary 
tubercles,  gummata,  sarcomata,  and  gliomata.  Until  ten  years  of 
age  the  tubercle  is  the  most  common  intramedullary  tumor,  whereas 
lipoma  and  sarcoma  are  the  most  frequent  extramedullary  tumors. 

Symptomatology. — This  depends  upon  the  nature  of  the  tumor, 
whether  intramedullary  or  extramedullary,  also  upon  its  position. 
The  symptoms  complained  of  result  from  pressure  upon  the  spinal 
roots,  spinal  marrow,  and  vertebral  column.  The  first  is  intense 
pain  of  nem-algic",  lancinating  character,  due  to  irritation  of  the  poste- 
rior roots.  The  location  of  the  pain  depends  entirely  upon  the  position 
of"  the  tumor.  Hj'peresthesia  and  certain  trophic  disturbances,  such 
as  herpes  zoster,  may  at  times  be  present.  These  may  be  the  only 
symptoms,  but  may  extend  over  several  years.  In  some  cases  the 
tumor  invoh'es  the  motor  roots,  and  causes  irritati^^e  symptoms — 
fibrillary  contractions,  or  even  true  muscle  spasms. 

As  a  result  of  compression  of  the  cord  there  is  paralysis  of  both 
the  sensory  and  motor  nerves,  which  arise  from  the  segments  of  the 
cord  in  which  the  tumor  lies.  There  is  also  flaccid  paralysis,  muscular 
atrophy,  the  reaction  of  degeneration,  loss  of  reflexes,  and  anesthesia 
as  regards  touch  and  pain. 

Indirect  spinal  sjTnptoms  due  to  interference  of  the  p^Tamidal  tract 
give  rise  to  spastic  hemiplegia  or  paraplegia,  according  to  the  extent 
of  the  involvement — whether  unilateral  or  bilateral — also  marked 
spasticity,  muscular  weakness,  exaggerated  reflexes,  the  Babinski 
and  Oppenheim  phenomena,  and  trophic  and  sphincter  disturbances. 
At  the  onset  the  lesion  is  usually  unilateral,  and  frequently  produces 
the  typical  Brown-Sequard  syndrome.  On  the  side  of  the  tumor  there 
is  (1)  paralysis  which  is  flaccid  at  the  level  of  the  lesion,  and  spastic 


TUMORS  OF   THE  SPINAL  CORD  807 

below;  (2)  disturbance  of  the  muscle  sense  while  other  senses  remain 
normal,  except  for  a  hyperesthetic  zone  above  the  paralysis  at  the 
level  of  the  tumor.  On  the  opposite  side  there  is  either  partial  or 
complete  anesthesia  to  pain  and  temperature. 

Unilateral  tumors  very  quickly  become  bilateral,  when  this  clas- 
sical syndrome  will  change  to  that  of  a  transverse  myelitis.  The 
symptoms  naturally  depend  upon  the  position  of  the  tumor.  Tumors 
in  the  cervical  region  give  rise  to  a  spastic  paralysis  of  all  the  extremi- 
ties, except  that  there  is  a  flaccid  paralysis  of  certain  groups  of  muscles 
of  the  arm.  If  the  upper  portion  of  the  arm  be  involved,  the  plirenic 
is  often  affected;  if  the  lower  portion,  the  forearm  and  hand  exhibit 
a  flaccid  paralysis.  Ocular  s\Tiiptoms  may  also  appear.  In  the  dorsal 
region  the  arm  remains  free  with  spasticity  of  the  lower  extremities, 
together  with  flaccid  paralysis  of  the  abdominal  muscles,  and  loss 
of  the  abdominal  reflexes.  If  located  in  the  lumbar  region  there  is 
general  flaccid  paralysis  of  the  lower  extremities.  The  most  frequent 
location  for  a  tumor  in  children  is  in  the  cauda  equina.  In  these  cases 
pain  in  the  sacral  region  is  very  severe,  and  extends  into  the  legs. 
The  paralysis  is  a  flaccid  one,  and  bladder,  rectal,  and  trophic 
disturbances  are  usually  present. 

As  a  result  of  pressure  upon  the  vertebral  column  and  erosion  of 
the  vertebrae  by  extramedullary  tumors,  one  occasionally  observes 
scoliosis  and  kyphosis.  Pain  on  percussion  of  the  vertebrae  is  fre- 
quently present.  Oppenheim  called  attention  to  an  impairment  of  the 
percussion  note  over  the  tumor. 

Diagnosis. — Intramedullary  tumors,  owing  to  their  unfavorable 
progress,  must  be  difterentiated  from  those  of  extramedullary  type 
which  are  more  amenable  to  treatment.  The  following  table  gives 
the  chief  points  in  the  differential  diagnosis;  yet  it  must  be  borne  in 
mind  that  the  differentiation  is  usually  not  easy,  and  frequently  is 
impossible : 

Intramedullary  Tumors.  Extramedullary  Tumors. 

Root  symptoms  usually  absent.  Root  symptoms  usually  present. 

No  pain  on  vertebral  percussion.  Pain  on  vertebral  percussion. 

Become  bilateral  quickly.  Remain  unilateral  for  a  longer  period : 

Brown-Sequard  syndrome. 
Remissions  frequent.  Remissions  rare. 

The  rapidity  with  which  the  intrameningeal  tumor  becomes  bilateral 
tends  to  mask  the  real  disease  and  obscure  the  diagnosis.  If  the 
anterior  horn  cells  be  involved,  progressive  muscular  atrophy  may 
be  suspected;  if  both  the  anterior  and  posterior  horn  cells,  s^Tingo- 
myelia  is  simulated;  if  of  diffuse  character,  then  transverse  myelitis 
may  be  thought  of.  In  addition,  spinal  s^-philis,  multiple  sclerosis, 
and  compression  myelitis  must  frequently  be  differentiated  from 
tumor. 

Course  and  Prognosis. — The  course  of  the  disease  is  usually  slow, 
extending  over  a  period  of  ten  to  twelve  years,  and  unless  operated 


808  THE  NERVOUS  SYSTEM 

upon,  terminating  fatally  as  a  result  of  the  extensive  paralysis  or  by 
some   intercurrent   infection. 

Treatment. — If  extradiu-al,  the  tumor  should  be  removed  surgically. 
Tumors  associated  with  spina  bifida,  and  brain,  metastatic  and 
extradural  tumors  are  not  amenable  to  operation.  When  sj^^hilis  is 
suspected,  antis^'philitic  treatment  should  be  begun  immediately. 


DISEASES   OF  THE  MENINGES. 

PACHYMENINGITIS. 

Pachymeningitis  is  an  inflammation  of  the  mucous  membrane  which 
lines  the  dura,  and  is  a  rare  disease  in  children.  We  distinguish  two 
forms  of  the  affection:  (1)  Pachymeningitis  externa;  and  (2)  pachy- 
meningitis interna. 

Pachymeningitis  Externa. — This  may  appear  either  in  a  chronic 
fibrous  form,  usually  associated  with  a  chronic  inflammation  of  the 
pia  arachnoid  (leptomeningitis  and  meningo-encephalitis) ,  or  be 
secondary  to  lesion  of  the  contiguous  bony  structures,  such  as  frac- 
ture of  the  skull,  or  tubercular  or  s^'philitic  periostitis.  Or  it  may  be 
acute,  and  secondary  to  inflammation  of  the  neighboring  bony  struc- 
tures, such  as  otitis  media,  mastoiditis,  caries  of  the  middle  ear,  puru- 
lent rhinitis,  or  inflammation  of  the  sinuses,  especially  the  frontal; 
it  may  lead  to  an  extradural  abscess  between  the  dura  mater  and 
bony  structiues. 

Symptoms. — In  many  mild  cases  there  are  no  characteristic  symp- 
toms; whereas,  m  the  more  severe  type  there  may  be  violent  headache 
with  localized  pain  on  pressrue  and  percussion.  In  the  most  aggra- 
vated cases  sjTiiptoms  of  intracranial  pressure,  i.  e.,  headache,  pro- 
jectile vomiting,  slow  pulse,  stupor,  and  choked  disk  may  appear. 
Focal  s^inptoms  are  usually  absent. 

Diagnosis. — Pachymeningitis  must  be  dift'erentiated  from  the  other 
complications  of  otitis  media;  namely,  purulent  sinus,  phlebitis,  brain 
abscess,  and  purulent  leptomeningitis. 

Treatment. — The  treatment  is  purely  surgical. 

Pachymeningitis  Interna. — Two  forms  of  pachymeningitis  interna 
are  distinguishable:  (1)  Purulent;  (2)  hemorrhagic. 

Purulent  Pachymeningitis  Interna. — The  piuulent  tj-pe  usually 
results  from  perforation  in  pachymeningitis  externa,  and  i»  associated 
with  inflammation  of  the  pia  mater  (leptomeningitis). 

Pachjoneningitis  Interna  Hemorrhagica.^ — Rosenberg,  of  Finkelstein's 
Clinic,  by  his  studies  of  pach\Tneningitis  interna  hemorrhagica,  has 
extended  our  knowledge  of  the  disease.  It  is  by  no  means  as  infre- 
quent as  was  formerly  supposed;  for  Rosenberg  collected  48  cases 
from  this  Clinic  within  four  years.  The  disease  can  now  be  diagnosed, 
is  amenable  to  treatment,  and  therefore  of  greater  interest. 


PACHYMENINGITIS  809 

Etiology. — Pachymeningitis  interna  hemorrhagica  is  usually  second- 
ary to  gastro-intestinal  disturbances,  malnutrition,  lues,  rickets,  scurvy, 
or  infectious  diseases,  especially  to  smallpox,  typhoid  fever,  and, 
occasionally,  to  pneumonia  and  tuberculosis.  Hemorrhagic  rhinitis, 
both  luetic  and  diphtheritic,  occurring  from  two  to  four  months  before, 
has  frequently  been  found  by  Rosenberg  to  be  an  etiological  factor. 
Children  cared  for  in  hospitals  and  institutions  are  more  susceptible 
on  account  of  their  greater  exposure  to  infection. 

Pathological  Anatomy. — The  lesions  are  bilateral,  and  are  on  the 
convexity  of  the  brain,  in  the  region  of  the  anterior  and  middle  fossae, 
and  over  the  region  of  the  middle  meningeal  artery  and  superior 
longitudinal  sinus. 

In  acute  cases  extravasations  are  observed  upon  the  inner  surface 
of  the  dura,  enclosed  in  a  fine  fibrinous  connective-tissue  membrane 
containing  leukocytes.  The  membrane  later  becomes  translucent. 
It  consists  of  fibrous  lamellae  containing  fibroblasts  and  newly  formed 
vessels  from  the  dura.  The  vessel  walls  are  thin,  being  lined  sunply 
with  endothelium.  Hemorrhage  takes  place  by  diapedesis  or  by  capil- 
lary bleeding,  as  a  result  of  which  hematoma  are  formed.  Rosenberg 
attributes  the  changes  to  thrombosis  of  the  sinus  cavernosus. 

Symptomatology. — The  clinical  picture  is  essentially  the  same 
as  that  seen  in  leptomeningitis,  except  that  fever  is  usually  lacking. 
Rosenberg  distinguishes  three  forms  of  the  disease,  grouped  as  follows : 

1.  The  latent  form,  which  may  show  merely  enlargement  of  the 
cranium,  open  and  distended  fontanelles,  and  a  widening  of  the  sutures. 
These  may  be  the  only  symptoms. 

2.  This  variety  sets  in  with  symptoms  of  acute  cerebral  pressure, 
giving  rise  to  vomiting,  headache,  convulsions,  rigidity  of  the  neck, 
stupor,  and  increased  reflexes. 

3.  A  rapid  form  with  severe  symptoms  arising  in  the  nervous  system, 
and  simulating  acute  leptomeningitis.  There  are  contractures  of  the 
extremities,  rigidity  of  the  neck,  fever,  coma,  convulsions,. strabismus, 
retinal  hemorrhages,  choked  disk,  and  a  positive  Kernig's  sign. 

Diagnosis. — Clinically,  the  disease  must  be  differentiated  from  sinus 
thrombosis,  leptomeningitis,  and  brain  tumor.  An  invaluable  aid 
to  the  diagnosis  is  a  study  of  the  cerebrospinal  fluid  obtained  by 
lumbar  puncture.  It  is  usually  clear,  and  under  increased  pressure. 
When  a  communication  exists  with  the  subarachnoid  space,  owing 
to  a  torn  pia,  the  fluid  will  be  either  hemorrhagic  or  of  a  lemon-yellow 
tint.  When  hemorrhage  due  to  faulty  technic  can  be  excluded,  these 
findings  are  pathognomonic. 

A  more  reliable  method  of  diagnosis  is  to  puncture  the  large  fontanelle, 
and  withdraw  some  cerebrospinal  fluid.  (For  the  technic  of  cerebral 
puncture  see  page  778.)  The  fluid  obtained  is  always  hemorrhagic, 
but  does  not  clot  upon  standing.  After  the  cells  have  settled,  it  is 
seen  to  be  of  a  light  lemon  color.  Examination  of  the  fluid  shows  no 
pathological  cellular  increase ;  there  is,  however,  an  increase  in  globulin , 
and  a  normal  reduction  of  Fehling's  solution. 


810  THE  NERVOUS  SYSTEM 

Clinical  Course  and  Prognosis. — Under  appropriate  treatment  the 
prognosis  is  more  favorable  than  was  formerly  supposed.  In  Rosen- 
berg's series  of  cases  there  were  16  recoveries  and  21  deaths;  only 
3  of  these  deaths  could  be  attributed  to  the  disease,  the  remainder 
being  due  to  intercurrent  infections.  Healing  follows  the  absorption  of 
the  fluid,  after  which  the  fontanelles  close,  the  cranium  again  assumes 
its  normal  shape  and  size,  and  there  is  a  corresponding  amelioration 
of  all  the  other  symptoms.  In  untreated  cases,  however,  death  takes 
place  within  a  few  weeks. 

Treatment. — There  should  be  absolute  rest  in  bed,  and  the  nutrition 
of  the  child  should  be  carefully  watched.  An  ice-bag  should  be  applied 
to  the  head,  and  lumbar  punctures  made  repeatedly,  removing  from 
50  to  100  c.c.  of  fluid  at  each  puncture.  Should  improvement  not 
follow,  cranial  aspiration  should  then  be  performed.  After  the  removal 
of  fluid,  hemorrhages  are  likely  to  recur,  and  horse  serum  or  human 
blood  serum  should  be  injected  intramuscularly  or  intravenously  as 
a  prophylactic.  If  bleeding  is  due  to  syphilitic  infection,  appropriate 
antis^']3hilitic  treatment  must  be  immediately  begun. 


ACUTE    SUPPURATIVE   MENINGITIS. 

Under  this  heading  may  be  grouped  all  forms  of  meningitis  except 
the  tuberculous  and  cerebrospinal,  which  are  considered  elsewhere 
in  this  work.  Acute  suppurative  meningitis  is  also  called  acute 
simple  meningitis,  acute  purulent  meningitis,  and  vertical  meningitis, 
although  it  cannot  be  considered  as  a  distinct  disease,  but  should 
be  regarded  as  a  pathological  condition  due  to  infection  by  any  one 
of  a  number  of  microorganisms. 

It  is  customary  to  designate  the  forms  of  meningitis  in  this  group 
according  to  the  causative  organism;  e.  g.,  influenzal  meningitis, 
streptococcic  meningitis,  and  pneumococcic  meningitis.  Clinically, 
these  forms  of  the  disease  so  closely  resemble  each  other  that  the 
grouping  of  all  the  various  t^'pes  seems  justified. 

Etiology. — ^Acute  purulent  meningitis  may  be  either  primary  or 
secondary,  the  primary  form  being  most  frequently  of  pneumococcic 
or  influenzal  origin,  while  secondary  meningitis  is  generally  caused 
by  the  staphylococcus.  ^Meningitis  may,  however,  arise  from  any 
acute  systemic  infection  with  bacteremia. 

Among  the  rare  causes  of  acute  purulent  meningitis  are  trauma 
and  insolation.  Meningitis  may  also  develop  from  the  extension  of 
a  suppiu"ative  process  in  the  scalp,  cranial  bones,  nasal  cavities,  the 
ear,  the  orbit,  and  the  face,  from  the  rupture  of  brain  abscesses,  or 
may  be  produced  by  more  distant  lesions,  the  infection  being  carried 
by  the  blood  or  the  lymph  stream. 

The  meninges  are  sometimes  the  site  of  infection  by  the  colon 
bacillus,  and  meningitis  may  also  accompany  scarlet  fever,  measles, 
diphtheria,    smallpox,    rheumatic    fever,    tj'phoid    fever,    erysipelas, 


ACUTE  SUPPURATIVE  MENINGITIS  811 

pneumonia  and  influenza,  and  may  occur  as  a  terminal  infection  in 
many  chronic  infectious  diseases. 

The  bacillus  pyocyaneus  and,  more  rarely,  the  gonococcus  are 
isolated  in  some  cases,  while  in  others  there  may  be  more  than  one 
variety  of  organism,  the  process  being  due  to  mixed  infection.  Chil- 
dren of  all  ages  are  attacked;  as  a  rule,  the  previous  state  of  health 
seems  to  have  no  influence  on  the  occurrence  of  this  meningeal  inflam- 
mation. Most  of  the  cases  occur  sporadically,  and  are  probably  more 
frequent  during  the  late  winter  and  spring  months  than  at  other 
seasons  of  the  year. 

Pathology. — The  dura  mater,  the  pia  mater,  or  both  may  be  affected; 
usually  the  pia  mater  is  most  extensively  involved,  the  inflammatory 
process  being  a  general  one;  but  it  may  also  be  more  or  less  localized 
to  a  limited  area.  Thus,  the  spinal  cord,  the  cortex  of  the  brain,  the 
ventricles  of  the  brain,  or  all  of  these  may  be  the  site  of  inflammation; 
or,  as  in  the  cases  where  there  is  infection  of  the  ear,  for  example, 
the  lesions  may  be  unilateral.  The  vessels  of  the  pia  are  congested, 
minute  hemorrhages  take  place,  and  serofibrinous  or  purulent  fluid 
bathes  the  parts.  The  convolutions  may  be  flattened,  and  the  pia 
arachnoid,  or  even  the  ventricles,  may  be  quite  distended.  As  a  rule 
there  is  associated  involvement  of  the  spinal  cord. 

When  the  inflammatory  process  is  confined  to,  or  is  most  extensive 
over,  the  vertex,  it  is  sometimes  termed  vertical  meningitis.  In  pneu- 
mococic  meningitis  the  bulk  of  the  exudate  and  many  adhesions  are 
found  in  the  upper  portion  of  the  brain.  Not  uncommonly',  the  ante- 
rior half  of  the  brain  may  be  encased  in  pus.  Microscopic  exami- 
nation of  the  affected  tissue  reveals  marked  congestion  of  the  blood- 
vessels and  round-cell  infiltration  in  the  inflammatory  areas. 

Symptoms. — In  the  majority  of  cases  of  acute  purulent  meningitis 
the  onset  is  sudden  and  the  symptoms  violent;  although  in  some 
instances  the  first  symptoms  of  meningitis  may  be  masked  to  a  con- 
siderable extent  by  the  primary  disease,  especially  if  this  be  erysipelas, 
septicemia,  or  pneumonia.  Drowsiness  and  stupor,  with  irregular 
respirations  and  pulse,  may  be  the  first  indications  of  meningitis. 
In  primary  cases,  due  to  the  pneumococcus  and  influenza  bacillus, 
vomiting  and  convulsions  usually  usher  in  the  attack.  As  a  rule  there 
is  an  initial  chill,  followed  by  a  sudden  rise  in  temperature,  severe 
headache,  increasing  delirium,  photophobia,  rigidity  and  retraction 
of  the  neck,  aimless  movements  of  the  legs  and  arms,  general  signs  of 
irritation,  dilatation  of  the  pupils,  and  finally  coma.  A  bulging  of 
the  anterior  fontanelle  is  often  apparent  in  young  infants,  and  Kernig's 
sign  is  present  in  all  cases. 

Diagnosis. — As  a  rule,  the  diagnosis  of  acute  purulent  meningitis 
can  readily  be  made  from  the  symptoms;  but  in  Order  to  determine 
the  particular  type  with  which  we  are  dealing  an  accurate  history 
must  be  taken,  the  symptoms  thoroughly  investigated,  and  a  bacte- 
riological examination  of  the  cerebrospinal  fluid  made.  Although  the 
symptoms  of  the  various  forms  of  meningitis  may  be  somewhat  dis- 


812  THE  NERVOUS  SYSTEM 

similar,  and  while  we  may  suspect  from  the  history  of  the  case  that 
a  certain  t^'pe  of  the  disease  is  present,  neither  of  these  circumstances 
is  of  any  practical  value,  and  the  only  conclusive  evidence  of  a  certain 
infection  is  the  finding  of  the  specific  organism  within  the  spinal  fluid. 

Pneumococcic  Meningitis. — Of  the  various  forms  of  meningeal 
inflammation  grouped  under  the  heading  of  acute  suppurative  menin- 
gitis, this  is  the  one  most  frequently  met  with  in  young  children.  It 
is  practically  always  associated  with  general  pneumococcic  infection 
and  pneumococcemia,  and  in  most  cases  there  is  a  demonstrable  lesion 
in  the  bronchi,  lungs,  pleurae,  pericardium,  or  peritoneum.  Although 
in  occasional  cases  no  pneumococcic  lesion  is  evident,  yet  at  post- 
mortem the  pneumococcus  can  invariably  be  isolated  from  the  heart's 
blood. 

The  meninges  usually  become  involved  during  the  height  of  an 
attack  of  pneumonia,  but  meningitis  occasionally  precedes  or  follows 
pulmonary  consolidation. 

As  a  rule,  in  any  series  of  cases  the  majority  will  be  found  to  occur 
in  infants  under  one  year  of  age.  At  autopsy  the  gross  changes 
resemble  those  of  cerebrospinal  meningitis,  but  there  is  little,  if  any, 
involvement  of  the  cord.  The  fibrinous  and  piu-ulent  exudation  is 
more  profuse  than  in  any  other  type  of  meningeal  inflammation. 

Symptoms. — The  symptoms  closely  resemble  those  of  cerebrospinal 
meningitis,  but  in  many  cases  there  is  entire  absence  of  rigidity,  cer- 
vical opisthotonos,  Kernig's  sign,  and  hyperesthesia,  while  the  pulse 
and  respirations  may  not  be  appreciably  altered.  The  onset  is  sudden, 
the  com-se  of  the  disease  is  short  and  violent,  being,  as  a  rule,  from  two 
to  eight  days,  rarely  longer.  A  positive  diagnosis  can  be  made  only 
by  examination  of  the  cerebrospinal  fluid,  which  is  cloudy,  under 
increased  pressure,  and  contains  an  excess  of  polynuclear  leukocytes 
and  many  pneumococci  grouped  in  short  chains. 

Septic  Meningitis — Streptococcic  Meningitis — Staphylococcic  Men- 
ingitis.— This  form  of  meningitis  is  usually  secondary,  and  is  a  com- 
plication of  septicemia,  otitis,  mastoiditis,  trauma,  erysipelas  of  the 
scalp,  sinus  thrombosis,  infection  of  the  umbilicus,  or  of  spina  bifida. 
The  sjTnptoms  are  not  quite  as  severe  as  in  pneumococcic  meningitis; 
but  the  disease  is  usually  fatal,  especially  the  streptococcic  t^'pe,  which 
is  more  severe  than  that  due  to  the  Staphylococcus  pyogenes. 

Examination  of  the  brain  reveals  diffuse  inflammation  of  the  pia 
and  a  profuse  purulent  exudate,  but  not  the  excess  of  fibrin  so  char- 
acteristic of  pneumococcic  meningitis.  The  cerebrospinal  fluid  is 
turbid,  is  under  increased  pressure,  and  contains  numerous  pus  cells 
and  streptococci  or  staphylococci,  the  streptococci  being  usually 
grouped  in  long  chains. 

Influenzal  Meningitis. — This  form  of  acute  purulent  meningitis 
occurs  in  association  w^ith  uifluenzal  infection  elsewhere  in  the  body, 
but  is  very  rare.  Infants  are  more  liable  to  attack  than  older  children. 
Most  of  the  reported  cases  have  been  secondary  to  involvement  of 
the  nose,  tkroat,  or  bronchi.    The  postmortem  findings  are  the  same 


ACUTE  SUPPURATIVE  MENINGITIS  813 

as  in  pneumococcic  meningitis,  and  the  influenza  bacillus  may  be  found 
in  the  heart's  blood  and  in  the  primary  lesions,  as  well  as  in  the 
cerebrospinal  fluid. 

Symptoms. — The  onset  of  this  form  of  meningitis  is  not  quite  so 
sudden  as  in  the  pneumococcic  type,  but  the  symptoms  are  acute  and 
violent.  In  the  great  majority  of  cases,  an  attack  ends  fatally  within 
a  few  days  after  the  appearance  of  the  initial  symptoms.  The  mor- 
tality in  influenzal  meningitis  is  not  quite  as  high  as  in  the  preceding 
forms  of  meningeal  inflammation  in  this  group,  but  recovery  is 
unusual. 

Diagnosis. — The  diagnosis  can  be  made  only  by  microscopic  exam- 
ination of  the  cerebrospinal  fluid  and  by  making  cultures  therefrom, 
since  the  influenza  bacilli  are  by  no  means  as  abundant  as  are  the 
infecting  organisms  in  other  forms  of  purulent  meningitis,  and  in  some 
cases  they  cannot  be  found  in  smears. 

The  cerebrospinal  fluid  is  turbid,  and  contains  many  polynuclear 
leukocytes  in  "addition  to  influenza  bacilli.  In  some  cases  organisms 
other  than  the  influenza  bacillus  are  present,  which  indicates  a  mixed 
infection. 

Typhoid  Meningitis. — Occasionally,  during  the  course  of  typhoid 
fever  in  children,  a  meningitis  which  is  purulent  in  character  will 
develop,  the  typhoid  bacillus  being  the  causative  organism.  The 
prognosis  in  this  typhoid  meningitis  is  slightly  more  favorable  than 
in  the  other  forms  of  purulent  meningitis,  although  recovery  occurs 
only  occasionally. 

Differentiation  of  Purulent  Meningitis  from  Other  Diseases. — Men- 
ingismus,  or  toxic  irritation  of  the  meninges,  occurring  during  the 
course  of  any  illness,  may  simulate  meningitis;  but  the  pulse  and 
respiration  do  not  become  irregular,  as  in  meningitis,  and  examina- 
tion of  the  spinal  fluid  is  negative.  Typhoid  fever  is  sometimes 
simulated  at  the  onset  of  m.eningitis;  but  in  meningitis  vomiting  is 
more  persistent,  there  is  rarely  diarrhea,  as  in  typhoid  f ever,  there  is  no 
marked  enlargement  of  the  spleen,  and  the  Widal  reaction  is  negative. 

Pneumonia  is  sometimes  mistaken  for  meningitis;  but  when  physical 
signs  become  appreciable  in  the  chest,  the  meningeal  symptoms  usually 
subside.  Uremia  may  be  excluded  by  luinalysis,  and  eclampsia  by 
an  accurate  history  of  the  case  and  by  study  of  the  patient  for  a  day 
or  two. 

Brain  tumors  may  be  excluded  by  the  absence  of  localizing  symp- 
toms, such  as  optic  neuritis,  paralyses,  and  other  evidences  of  a  definite 
local  lesion. 

Prognosis. — The  prognosis  in  acute  purulent  meningitis  is  most 
unfavorable,  and  in  all  the  various  types  of  the  disease  a  large  majority 
of  the  children  perish.  The  mortality  varies  from  65  to  85  per  cent., 
and  is  lowest  in  those  cases  where  operation  is  resorted  to  for  relief. 

Treatment. — Acute  purulent  meningitis,  secondary  to  infection  of 
the  head,  ears,  or  face,  is  sometimes  greatly  modified  by  free  drainage 
of  the  infected  area.    Antimeningococcic  serum  is  of  no  value  in  this 


814  THE  NERVOUS  SYSTEM 

form  of  meningitis,  but  repeated  lumbar  punctures  will  relie\-e  the 
pressure  symptoms.  In  influenzal  meningitis  a  specific  serum  has 
been  used  by  Wollstein,  of  the  Rockefeller  Institute,  and  others  with 
good  results.  In  the  staphylococcic  variety,  homogeneous  vaccines 
may  be  of  service  if  given  early  in  the  course  of  the  disease. 

The  general  management  of  acute  purulent  meningitis  is  the  same 
as  that  of  other  forms  of  meningeal  inflammation,  although  in  many 
cases  little  can  be  done,  except  to  provide  nourishment  for  the  child 
and  make  it  as  comfortable  as  possible.  Warm  baths  or  a  hot  pack 
may  be  given  three  or  four  times  a  day,  and  ice-bags  applied  to  the 
head  and  along  the  spine.  The  child  should  be  kept  in  a  quiet,  dark, 
and  well  ventilated  room. 

If  restless,  2  to  5  grains  of  sodium  bromide,  with  ^  to  1  grain  of 
chloral  hydrate,  may  be  gi\-en  e^'ery  two  or  three  hoius  to  infants,  and 
twice  this  dose  to  older  children.  If  rectal  administration  is  necessary, 
the  dose  should  be  double  that  given  by  mouth. 

In  very  severe  cases  it  may  be  necessary  to  administer  morphine 
sulphate,  tut  to  -V  of  a  grain  hypodermically,  or  codeine  sulphate, 
sV  to  :j^  of  a  grain  at  4-  to  6-hour  intervals'  or  hyoscine  hydrobro- 
mate,  -g-g-Q-  to  g^j-jj  of  a  grain. 

The  bowels  should  be  kept  regular  by  giving  small  doses  of  calomel, 
iV  to  T  grain,  during  the  day,  or  by  the  administration  of  a  daily  dose 
of  |-  to  ^  teaspoonful  of  cascara  sagrada. 

Feeding  is  often  attended  by  much  diSiculty.  A  liquid  diet  is 
preferable,  and  milk  is  the  best  food;  but,  in  many  cases,  the  child 
refuses  food,  while  in  others  it  is  unable  to  swallow.  Nutrient  enemata 
may  be  resorted  to,  but  the  bowel  soon  becomes  irritable  and  unable 
to.  retain  them,  and  gavage  is  then  necessary. 

The  nose  and  mouth  must  be  kept  absolutely  clean.  In  feeding 
the  child  who  cannot  swallow  there  is  always  danger  that  food  may 
pass  into  the  air  passages.  Bed-sores  soon  develop  unless  the  child's 
skm  is  kept  clean  and  dry,  and  precautions  are  taken  to  prevent 
pressure. 

Stimulation  is  rarely  of  any  permanent  value;  but,  when  required, 
brandy,  10  to  .30  drops,  strychnine  sulphate,  ^^^  to  you  of  a  grain, 
atropine  sulphate,  g-^  to  ^d-it  of  a  grain,  or  camphorated  oil,  one  to 
three  drops,  may  be  given  every  two  or  three  hours. 

CEREBROSPINAL   MENINGITIS— EPIDEMIC   MENINGITIS. 

Definition. — This  is  a  specific  infection  of  the  meninges  of  the  cere- 
brospinal tract,  caused  by  the  diplococcus  intracellularis  meningitidis 
of  Weichselbaum,  and  occurs  both  epidemically  and  sporadically. 

Etiology  and  Epidemiology. — Epidemic  cerebrospinal  meningitis  is  a 
disease  of  both  winter  and  spring,  reaching  its  height  between  Feb- 
ruary and  ]May.  Xo  country  has  been  free  from  its  ravages, 
although  countries  of  the  north  temperate  zone,  especially  those  of 
Central  Europe  and  our  own  northeastern  States  have  suffered  most. 


CEREBROSPINAL  MENINGITIS  815 

Age  is  of  considerable  importance,  since  it  chiefly  afl^ects  those  under 
three  years,  the  incidence  diminishing  as  the  age  increases.  Males 
and  females  seem  equally  susceptible.  Occupation  and  hygienic  con- 
ditions play  important  roles  in  the  etiology;  thus,  soldiers  housed 
in  barracks,  miners,  and  inmates  of  prisons  and  almshouses  are 
especially  susceptible. 

The  diplococcus  is  almost  invariably  present,  especially  in  the 
early  stages  of  the  disease,  in  the  nasopharynx,  particularly  the 
upper  part,  and  in  the  posterior  nares.  By  making  a  swab,  and 
then  microscopic  preparations,  properly  stained,  these  diplococci 
can  be  found.  Albrecht  and  Shon  demonstrated  that  healthy  persons 
entirely  free  from  the  disease  may  harbor  the  cocci  in  the  nasopharynx; 
and,  according  to  Horder,  the  number  of  these  healthy  carriers  varies 
from  ten  to  thirty  for  every  case  of  cerebrospinal  meningitis  occurring 
during  an  epidemic.  Usually  the  diplococcus  persists  for  three  to 
four  weeks  after  convalescence  has  set  in.  With  regard  to  the  carriers 
the'  cocci  may  be  isolated  even  after  several  months,  sometimes 
disappearing  for  a  time,  and  then  reappearing. 

All  evidence  points  to  direct  contact  as  the  means  of  dissemination. 
Owing  to  the  low  degree  of  vitality  of  the  organism,  dissemination 
takes  place  through  minute  droplets  of  the  secretion  in  coughing, 
speaking,  or  sneezing. 

Pathogenesis. — The  portal  of  entrj^  of  the  infecting  organism  is  the 
mucous  membrane  of  the  nasopharynx,  where  it  sets  up  a  pharyn- 
gitis, and  from  a  study  of  recent  epidemics  it  would  seem  that  the  cocci 
reach  the  meninges  through  the  lymph  and  blood  streams — lympho- 
hematogenous — this  being  the  most  frequent  and  the  earliest  manifes- 
tation of  meningococcic  septicemia. 

Pathological  Anatomy. — In  the  acute  fulminating  cases  leading 
quickly  to  death,  there  are  either  no  visible  changes  or  only  hyperemia 
of  the  meninges.  In  the  ordinary  acute  cases  a  purulent  exudate, 
which  is  usually  thick  and  yellowish  green,  is  deposited  in  the  meshes 
of  the  pia,  chiefly  at  the  base,  especially  around  the  optic  chiasm, 
and  extending  to  the  cranial  nerve-roots,  cerebellum,  spinal  meninges, 
and  to  the  convexity  of  the  brain.  The  ventricles  are  distended  with 
a  turbid  seropurulent  exudate  containing  flakes  of  fibrin;  sometimes 
it  is  purely  serous,  and  leads  to  hydrocephalus.  The  choroid  plexus 
and  ependyma  are  always  involved.  Everj^^where  Gram- negative 
diplococci  can  be  found  microscopically.  At  a  late  stage  of  the  disease, 
when  the  infection  has  subsided  and  convalescence  has  set  in,  the 
exudate  has  disappeared,  and  is  replaced  by  fibrous  thickening  of 
the  pia  arachnoid. 

Symptoms. — Although  prodromal  symptoms  of  indisposition  and 
slight  headache  may  be  present  for  three  to  four  days,  usually  the 
onset  is  very  sudden,  with  fever,  with  or  without  a  chill,  intense  head- 
ache, vomiting,  rigidity  of  the  neck,  and  general  malaise.  The 
temperature  varies  between  102°  and  104°  F.,  with  a  corresponding 
increase  in  pulse  rate.     The  headaches  are  usually  occipital,  and  very 


816  THE  NERVOUS  SYSTEM 

severe.  Vomiting  may  be  almost  continuous  in  young  children,  but 
less  persistent  in  small  infants  and  young  adults.  There  may  be 
slight  stupor,  or  even  delirium,  during  the  initial  period,  which  usually 
lasts  from  two  to  four  days,  following  which  symptoms  of  meningeal 
irritation  develop. 

The  vomiting  persists,  there  is  loss  of  appetite,  obstinate  consti- 
pation, and  the  abdomen  becomes  markedly  scaphoid.  The  pulse 
is  rapid  and  irregular;  the  respirations  are  also  irregular.  The  fever 
usually  runs  a  variable  course,  or  may  be  intermittent,  with  days  of 
normal  temperature.  Following  the  initial  stage,  the  sensorium 
usually  clears  during  the  first  week.  In  severe  cases  the  spleen  is 
enlarged.  Albuminuria  is  a  frequent  accompaniment;  at  times  there 
is  slight  glycosuria.  Herpes  is  quite  common.  Other  skin  rashes, 
such  as  large  rose  spots,  small  petechise,  and  rashes  simulating  measles, 
scarlet  fever,  and  urticaria  are  observed. 

Nervous  Symjjtoms. — ^The  most  important  symptom  of  irritation  is 
rigidity  of  the  neck,  which  may  be  marked;  on  any  attempt  to  move 
it,  the  patient  will  resist  and  complain  of  severe  pain.  Bruidzinski's 
sign  (flexion  of  the  lower  extremities  on  acute  flexion  of  the  head)  is 
positive.  Opisthotonos  may  likewise  be  extreme.  The  legs  are  drawn 
up.  Kernig's  sign  is  positive,  and  a  positive  Babinski  sign  may  also 
be  present.  Tonic  convulsions  of  the  muscles  of  the  extremities, 
abdomen,  and  face,  are  frequent;  likewise  clonic  convulsions,  especi- 
ally involving  the  face.  Convulsions  simulating  epilepsy,  at  times 
Jacksonian,  are  observed. 

Hyperesthesia  and  hyperalgesia  are  most  pronounced.  In  addition 
there  is  photophobia  and  susceptibility  to  noises.  The  vasomotor 
system  is  also  afi'ected,  giving  rise  to  the  familiar  tache  cerebrale. 
Cranial  and  peripheral  palsies  are  rare.  The  reflexes  are  variable; 
the  deep  reflexes  are  usually  increased,  although  they  may  be  normal, 
diminished,  or  absent.  The  superficial  reflexes  are  likewise  quite 
variable;  they  are  usually  increased,  but  later  disappear.  The  pupils 
may  be  dilated  or  contracted,  and  unequal.  The  reactions  are  usually 
sluggish  or  absent. 

The  stupor  is  not  so  deep  as  in  other  forms  of  meningitis,  for  the 
patient  can  usually  be  aroused.  There  may  be  delirium  and  marked 
insomnia.     In  infants  the  fontanelles  are  bulging. 

Clinical  Forms  and  Course. — Horder  distinguished  the  following  forms 
of  cerebrospinal  meningitis: 

1.  The  ordinary,  or  acute,  type  just  described. 

2.  Super  acute  type. 

3.  The  fulminating,  or  malignant,  type. 

4.  Mild  type. 

5.  Postbasic]  meningitis    of    infants — cervical    opisthotonos    of 

infants  (Gee  and  Barlow). 

6.  Aberrant  forms: 

(a)  Abortive. 

(b)  Intermittent. 

(c)  Cases  simulating  other  diseases. 


CEREBROSPINAL  MENINGITIS  817 

In  the  superacute  forms  the  symptoms  are  more  intense,  and  the 
patient  usually  succumbs  within  two  or  three  days.  In  the  fulminat- 
ing type  death  may  take  place  within  twelve  hours.  In  milder  forms, 
the  sj'mptoms  are  less  severe.  This  is  common  during  epidemics, 
and  unless  a  careful  examination  is  made  and  a  lumbar  puncture 
performed,  it  may  go  unrecognized.  The  abortive  cases  are  to  be 
recognized  only  during  epidemics;  they  exhibit  slight  fever,  vomiting, 
and  stiffness  of  the  neck,  all  of  these  symptoms  clearing  up  within 
several  hours.  The  post-basic  meningitic  form  is  characterized  by 
extreme  retraction  of  the  head,  marked  opisthotonos  (the  head  fre- 
quently approximating  the  buttocks),  vomiting  and  extreme  emaciation. 

Course  in  Acute  Type. — ^The  disease  either  ends  in  recovery,  inter- 
rupted by  recrudescence,  or  becomes  chronic,  and  the  emaciation 
extreme.  Incontinence  and  bed-sores  develop,  and  muscular  rigidity 
becomes  marked.  The  disease  may  continue  for  months  and,  although 
recovery  may  take  place  and  leave  no  residual  defects,  yet  usually 
mental  deficiency,  blindness,  deafness,  or  palsies  follow.  Death  may 
ensue  at  any  time  during  the  course  of  the  disease. 

Diagnosis. — ^The  characteristic  signs  and  symptoms,  which  are 
especially  noticeable  during  an  epidemic,  will  usually  arouse  one's 
suspicions  of  meningitis.  An  absolute  diagnosis  can  be  made  only 
by  thorough  examination  of  the  cerebrospinal  fluid,  the  findings  in 
which  are  as  follows: 

(1)  The  spinal  fluid  is  both  increased  in  amount  and  under  increased 
pressure.  (2)  The  fluid  shows  turbidity  which  varies,  being  slight  in 
the  invasive  stage,  and  marked  during  the  active  stage,  later  clearing 
as  the  inflammation  subsides.  (3)  The  globulin  is  always  increased, 
the  amount  depending  upon  the  stage  of  inflammation.  (4)  The  fluid 
does  not  reduce  Fehling's  solution.  (5)  Cytology:  During  the  invasive 
stage  the  lymphocytes  predominate,  but  on  the  advent  of  acute  inflam- 
mation the  polynuclear  cells  predominate,  ranging  between  70  and 
80  per  cent.  Later,  when  the  inflammatory  stage  subsides  and  chronic 
hydrocephalus  becomes  more  pronounced,  there  will  be  a  predomi- 
nance of  lymphocytes.  (6)  Bacteriology  of  the  fluid:  Intracellular 
meningococci  can  usually  be  seen  some  time  during  the  first  ten  days. 
The  fact  that  they  are  not  perceptible  in  smears  does  not  necessarily 
indicate  that  they  are  absent,  and  the  fluid  should  always  be  cultured 
on  appropriate  culture  media. 

Complications. — Joint  complications,  either  monarticular  or  poly- 
articular involvement,  are  observed.  Inflammations  of  the  eye — 
panophthalmia,  iritis,  iridocyclitis,  usually  unilateral,  and  leading 
frequently  to  blindness — also  inflammation  of  the  inner  ear,  generally 
bilateral,  giving  rise  to  deafness,  are  all  observed.  Empyema,  peri- 
carditis, and  endocarditis  are  rare  complications.  Chronic  hydro- 
cephalus frequently  follows  this  disease. 

Prognosis. — Since  the  use  of  Flexner's  serum  the  death-rate  has 
fallen  from  70  to  80  per  cent,  to  about  30  to  40  per  cent.  The  mor- 
tality is  highest  in  young  infants,  especially  in  the  early  stages  of 
52 


818  THE  NERVOUS  SYSTEM 

the  disease.  The  prognosis  cannot  be  made  by  examination  of  the 
spinal  fluid  alone;  but  the  greater  the  number  of  intracellular  cocci 
the  better  will  be  the  outlook,  and  vice  versa. 

Prophylaxis. — Since  we  now  know  that  the  mode  of  dissemination 
of  the  cocci  is  through  the  buccal  secretions,  care  must  be  taken  to 
prevent  direct  contact.  Strict  quarantine  should  be  established,  just 
as  for  other  infectious  diseases,  and  the  same  precautions  observed 
in  regard  to  the  disposition  of  the  urine,  feces,  and  infected  fomites, 
as  well  as  thorough  fumigation  after  recovery. 

Even  more  important  is  the  treatment  of  the  carriers,  as  it  is  by 
them  that  the  disease  is  really  spread.  They,  likewise,  should  be 
placed  under  quarantine  until  the  nasopharynx  is  free  from  cocci, 
which,  under  the  use  of  antiseptic  gargles  and  sprays,  is  usually  in 
about  ten  days.  All  healthy  persons  should  avoid  the  predisposing 
causes — exposure  to  severe  cold,  catarrhal  affections,  and  overcrowding. 

Treatment. — Several  immune  specific  sera  have  been  made.  The  one 
in  general  use  in  America  is  that  of  Flexner.  It  must  be  administered 
by  the  intraspinal  route,  the  method  being  as  follows: 

A  lumbar  puncture  should  be  made,  and  the  tm-bid  fluid  withdrawn 
in  an  amount  always  equal  to,  or  greater  than,  the  quantity  of  serum 
to  be  injected.  The  serum  should  then  be  slowly  injected,  either  with 
a  syringe  or  by  the  gravity  method,  the  time  allowed  for  the  injection 
being  about  ten  minutes.  The  usual  dose  is  20  c.c,  and  a  dose  larger 
than  this  must  be  given  with  extreme  care,  even  though  a  large  quan- 
tity of  spinal  fluid  has  been  withdrawn.  This  procedure  is  repeated 
daily  until  the  spinal  fluid  has  been  sterile  for  several  days,  and  the 
patient  clinically  shows  great  improvement. 

If  the  case  is  progressing  favorably  the  spinal  fluid  clears,  and  les- 
sens in  amount  and  pressure,  the  leukocytes  rapidly  diminish,  the 
meningococci  disappear,  and  the  power  to  reduce  Fehling's  solution 
— of  considerable  importance  in  the  prognosis — reappears.  If  there 
is  a  relapse,  the  same  treatment  is  repeated.  Autogenous  vaccines 
have  also  been  employed,  but  as  yet  without  convincing  results. 

If  meningococcic  septicemia  develops,  the  serum  should  be  admin- 
istered intravenously;  in  hydrocephalus  should  be  injected  directly 
into  the  lateral  ventricles;  and  in  severe  joint  afi^ections  it  should  be 
introduced  directly  into  the  joint. 

The  general  treatment  is  of  the  utmost  importance.  The  patient 
must  be  kept  quiet,  preferably  in  a  dark  room,  and  must  be  given 
plenty  of  fresh  air.  An  ice-cap  should  be  kept  on  the  head.  Hydro- 
therapeutic  measures,  such  as  warm  baths,  will  allay  the  nervous 
symptoms.  Hexamethylenamin  should  be  given  routinely — five 
grains  three  or  four  times  a  day  to  a  child  five  years  old.  Sedatives, 
preferably  some  preparation  of  opium,  may  be  necessary  on  account 
of  the  pain  and  delirium.  Morphine,  gr.  yV,  may  be  given  hypoder- 
mically  to  a  child  of  five  years,  and  if  necessary  the  dose  may  be 
repeated.  Every  precaution  must  be  taken  to  guard  against  bed-sores 
and,  if  possible,  the  patient  should  lie  on  a  water  bed. 


TUBERCULOUS  MENINGITIS  819 

The  nourishment  of  the  child  should  receive  most  careful  atten- 
tion. When  necessary,  feeding  by  gavage  is  usually  more  satisfactory 
than  by  rectum.  Attention  should  be  given  the  bladder,  bowels,  eyes, 
skin,  and  ears,  and,  should  any  complications  develop,  they  should 
receive  appropriate  treatment. 

TUBERCULOUS   MENINGITIS. 

Tuberculous  meningitis,  the  most  common  form  of  meningitis,  is 
a  tuberculous  inflammation  of  the  cerebrospinal  meninges,  developing 
secondarily  to  some  tuberculous  focus  elsewhere  in  the  body  or  as  a 
part  of  a  general  tuberculosis. 

Etiology. — Tuberculous  meningitis  is  a  disease  of  early  childhood, 
occurring  most  frequently  between  the  second  and  sixth  years.  It 
has  been  observed  as  early  as  the  third  month,  and  after  the  sixth 
month  has  been  found  quite  frequently.  After  the  sixth  year,  cases 
of  the  disease  rapidly  diminish.  The  sexes  seem  equally  affected. 
The  disease  is  most  common  in  the  early  spring,  from  March  to  May. 
Breast-feeding  offers  no  immunity  to  this  infection. 

The  disease  is  always  caused  by  the  tubercle  bacillus.  The  cerebro- 
spinal meninges  are  never  involved  primarily;  but  the  infection  arises 
from  some  latent  tuberculous  focus  elsewhere  in  the  body,  such  as  the 
caseous  bronchial,  cervical,  mediastinal,  or  mesenteric  lymph  glands, 
lesions  in  the  lungs,  pleurae,  bones,  joints,  and  intestines,  or  tubercu- 
lous meningitis  may  be  merely  a  part  of  a  general  miliary  tuberculosis. 

Pathogenesis. — ^The  pathogenesis  of  tuberculosis  in  children  is  con- 
sidered in  the  chapter  on  Tuberculosis.  It  seems  well  established 
by  the  studies  of  von  Pirquet,  Hamburger,  and,  more  recently,  by 
those  of  Dunn  that  in  the  great  majority  of  cases  infection  takes  place 
through  the  respiratory  tract,  that  the  bacilli  lodge  in  the  lung  where 
they  set  up  a  primary  focus  of  infection,  and  that  the  regional  lymph 
glands  become  secondarily  involved  through  the  lymph  vessels. 

From  the  primary  focus  of  infection  the  bacilli  invade  the  bronchi, 
thence  pass  to  the  nasopharynx  and  its  regional  lymph  glands.  By 
the  swallowing  of  the  bacilli  in  the  sputum  they  reach  the  intestinal 
tract,  thence  the  mesenteric  lymph  glands,  and  peritoneum.  Occa- 
sionally, through  drinking  milk  infected  with  the  bovine  type  of 
bacillus,  the  intestinal  tract  is  the  primary  seat  of  the  lesion. 

The  most  frequent  mode  of  infection  of  the  meninges  is  through 
the  blood  stream,  either  directly  from  the  primar}^  focus  in  the  lungs 
or  from  some  secondary  focus,  such  as  a  caseous  lymph  gland,  which 
perforates  into  a  vein,  and  causes  the  dissemination  of  the  bacilli  to 
all  the  organs  of  the  body,  setting  up  a  miliary  tuberculosis.  Peritz 
attributes  the  frequency  with  which  meningitis  develops  in  the  child 
to  the  increased  demand  for  blood  on  the  part  of  the  rapidly  growing 
brain. 

In  addition  there  are  a  number  of  factors  which  have  an  exciting 
influence  upon  these  tuberculous  foci,  and  lead  to  tuberculous  menin- 


820  THE  NERVOUS  SYSTEM 

gitis.  Thus  certain  infections,  especially  measles  and  whooping-cough, 
predispose  to  tuberculous  meningitis,  possibly  owing  to  diminished 
resistance  due  to  these  infections.  Trauma,  such  as  injury  to  the 
head,  tuberculous  glands  or  joints,  or  operations  for  the  removal  of 
glands,  may  cause  a  dissemination  of  bacteria,  either  by  direct  injury 
to  the  active  focus,  or  by  a  lessening  of  the  resistance  of  the  arachnoid 
membrane,  such  as  is  caused  by  a  blow  upon  the  head.  Overexertion, 
mental  excitement,  and  strain  have  precipitated  tuberculous  menin- 
gitis. 

In  rare  cases  the  meninges  may  be  infected  by  tuberculosis  of  the 
contiguous  structures,  such  as  caries  of  the  inner  ear,  vertebrae,  or 
cranial  bones. 

Pathological  Anatomy. — Tuberculous  meningitis  is  primarily  a  basilar 
meningitis.  The  most  important  pathological  changes  are  the  miliary 
tubercles  and  the  inflammatory  exudate  which  are  found  especially 
at  the  base  of  the  brain  around  the  circle  of  Willis  and  optic  chiasm, 
extendmg  into  the  Sylvian  fissure,  and  out  over  the  pons,  the  base 


Fig.  83. — Opisthotonos  in  tuberculous  meningitis;   a  boy  six  years  of  age. 

of  the  medulla  oblongata,  the  cerebellum,  and  spinal  meninges.  The 
exudate  is -either  gelatinous,  serofibrinous,  or  greenish-yellow  and  of 
fibrinopiu-ulent  character;  owing  to  its  consistency,  it  is  adherent 
to  the  pia.  The  amount  of  exudate  is  relatively  small  compared  with 
that  in  other  types  of  meningitis. 

The  tubercles,  either  transparent  or  of  a  greenish-white  color,  are 
especially  numerous  about  the  base  of  the  cerebrum.  They  are  often 
observed  arranged  in  rows  along  the  ^^essels  of  the  Sylvian  fissure 
after  the  removal  of  the  pia.  The  convexity  of  the  brain  is  less 
involved,  although  there  may  be  cloudiness,  and  an  infiltration  of 
the  pia  with  tubercles.  The  ependyma  and  choroid  plexus  of  the 
lateral  ventricles  are  also  invaded  by  tubercles  with  resulting  internal 
hydrocephalus.  The  ventricles  become  filled  and  distended  w^ith  a 
clear  serous  fluid,  or  it  may  be  bloody.  As  a  result  of  pressiu-e  the 
walls  may  be  softened,  the  convolutions  flattered,  the  fontanelles 
bulgmg,  and  the  sutures  separated. 

The  dura  may  at  times  exhibit  a  mild  pachymeningitis  interna 
hemorrhagica,  or  may  be  infiltrated  with  tubercles.     The  cerebral 


TUBERCULOUS  MENINGITIS  821 

cortex  is  always  involved.  Tubercles  may  invade  the  cortex  and 
caseate,  giving  rise  to  a  meningo-encephalitis. 

Symptoms. — The  onset  of  the  disease  is  usually  slow  and  gradual, 
occurring  most  frequently  in  weak,  anemic,  and  poorly  nourished 
children.  On  the  other  hand,  children  presenting  the  very  picture  of 
health  may  likewise  be  affected.  The  disposition  of  the  child  slowly 
changes,  and  it  loses  interest  in  its  play,  becomes  irritable,  fretful, 
peevish,  easily  tired,  moody,  wishes  to  be  let  alone,  cannot  be  pleased, 
and  is  drowsy  and  sleepy.  Its  sleep  is  restless,  interrupted  by  slight 
delirium,  or  there  may  be  insomnia.  Headache,  which  at  first  is  mild 
and  periodic,  rapidly  becomes  more  severe  and  persistent.  Symptoms 
referable  to  the  gastro-intestinal  tract  develop.  There  is  loss  of  appe- 
tite, vomiting,  pain  in  the  abdomen,  and  severe  constipation.  The 
vomiting  is  cerebral  in  character,  projectile,  and  is  unassociated  with 
nausea  or  time  of  eating. 

These  prodromal  symptoms  last  from  several  days  to  weeks,  or 
even  months,  in  which  time,  however,  symptoms  of  cerebral  irri- 
tation have  gradually  developed.  There  is  hyperesthesia  of  the  skin 
and  sense  organs.  The  patient  is  susceptible  to  harsh  voices  or  bright 
lights;  merely  the  slightest  touch  is  painful.  In  addition  there  are 
certain  vasomotor  phenomena,  such  as  transient  flushing  of  the  cheeks, 
face,  and  body.  The  well-known  tache  cerebrale  is  almost  always 
present.  This  is  an  irritation  of  the  skin,  manifested  by  a  red  streak 
which  appears  when  the  finger-nail  is .  drawn  over  the  skin  of  the 
abdomen. 

There  are  also  slight  symptoms  of  motor  irritation.  The  child  per- 
forms certain  stereotyped  movements;  it  picks  at  its  lips,  genitals, 
and  bed-linens,  winks  its  eyes,  grinds  its  teeth,  performs  sucking  and 
chewing  motions,  and  from  time  to  time  takes  deep  sighing  inspirations. 

At  this  stage,  although  drowsy,  the  child  may  answer  questions 
coherently.  The  temperature  is  usually  elevated  in  the  evening  to 
100°  or  even  102°  F.,  the  pulse  is  usually  between  70  and  80,  and 
exhibits  marked  arrhythmia.  The  patulous  fontanelles  may  be  dis- 
tended and  pulsating.  The  pupils  are  usually  contracted,  and  react 
promptly.  Exaggerated  reflexes  are,  as  a  rule,  present,  although 
they  may  be  unequal.  Slight  rigidity  of  the  neck,  back,  and  lower 
extremities  may  give  rise  to  a  positive  Kernig's  sign,  also  to  Bruid- 
zinski's  sign  (on  passive  flexion  of  the  head  upon  the  chest,  the  thighs 
are  drawn  up  upon  the  abdomen). 

The  symptoms  of  cerebral  pressure  and  irritation  grow  worse. 
The  drowsiness  increases,  and  the  child  sinks  into  a  stupor  from  which, 
however,  it  can  be  aroused.  Acute  irritative  symptoms  may  set  in, 
with  severe  headache,  delirium,  convulsions,  and  finally  deep  stupor. 
The  delirium  is  usually  mild.  The  child  lies  almost  asleep,  with  its 
eyes  half-open,  and  performs  stereotyped  movements,  utters  inco- 
herent sounds,  and  throws  itself  back  and  forth  on  the  bed  or  fre- 
quently utters  piercing  shrieks — the  hydrocephalic  cry.  Stupor 
follows  the  delirium,  or  they  may  alternate. 


822  THE  NERVOUS  SYSTEM 

Wlien  the  sensorium  again  clears,  severe  headache  and  dizziness 
are  complamed  of.  There  is  increased  susceptibility  to  strong  light 
• — ^photophobia — and  to  loud  noises;  the  symptoms  of  motor  irri- 
tation are  increased;  the  rigidity  of  the  muscles  of  the  neck,  trunk, 
and  extremities  also  increases.  Tetanic  contractions  of  the  muscles 
of  the  jaw  and  face  may  take  place,  while  contractions  of  the  flexor 
muscles  of  the  lower  extremities  give  rise  to  a  characteristic  posture; 
i.  e.,  the  patient  lies  upon  the  side,  with  the  thighs  flexed  upon  the 
abdomen,  and  the  legs  upon  the  hips.  The  abdomen  is  usually 
retracted,  which  gives  it  a  "boat-shaped"  appearance.  As  a  result 
of  the  extreme  emaciation  the  intestines  can  be  readily  palpated. 

Paralyses  are  quite  frequent,  and  cranial  nerve  palsies  common, 
owing  to  the  extensive  basilar  involvement.  There  are  ptosis,  dilata- 
tion, and  inequality  of  the  pupils,  strabismus,  and,  occasionally, 
complete  ophthalmoplegia.  The  pupils  react  slowly  to  light  or  are 
inactive.  Nystagmoid  movements  are  often  seen.  Examination  of 
the  eye-ground  frequently  shows  a  choked  disk  and  the  presence  of 
miliary  tubercles  in  the  choroid.  Facial  paralysis  is  also  often  observed. 
Paralyses  of  the  extremities,  such  as  monoplegia  or  hemiplegia,  may 
follow  convulsions,  which  may  be  either  partial  or  complete;  if 
unilateral,  they  may  simulate  a  Jacksonian  epileptic  seizm-e. 

The  reflexes  are  usually  increased.  A  positive  Babinski  phenomenon 
may  or  may  not  be  present.  As  unconsciousness  deepens  the  reflexes  ' 
are  lost,  the  temperature  rises,  and  the  breathing  becomes  Cheyne- 
Stokes.  Remissions  in  this  state  are  not  rare;  they  are  only  tem- 
porary, however,  and  after  several  days  of  improvement  the  patient 
falls  into  the  final  stage  of  coma. 

In  this  stage  there  is  complete  unconsciousness,  a  relaxation  of  the 
hitherto  rigid  extremities  and  neck,  the  reflexes  are  gone,  the  pupils 
are  dilated  and  show  no  reaction,  the  vomitmg  and  the  outcries  cease. 
There  may  be  either  retention  of  urine  or  mcontinence  of  both  lu-ine 
and  feces.  The  pulse  always  becomes  rapid  and  feeble,  frequentlj^ 
170  to  200  or  more  per  mmute;  the  temperature  rises,  and  during  the 
last  few  days  may  reach  106°  to  107°  F.;  it  may,  however,  be  sub- 
normal. Death  usually  follows,  or  may  occur  during  a  convulsion. 
This  final  stage  extends  over  a  period  of  three  to  ten  days,  while  the 
duration  of  the  whole  disease  after  definite  symptoms  have  appeared 
is  from  two  to  four  weeks. 

Atypical  Cases. — Acute  Cases. — In  a  few  cases  the  onset  is  very  acute, 
the  disease  settmg  m  with  convulsions,  after  which  the  patient  quickly 
falls  mto  coma,  which  termmates  in  death  withm  a  few  days. 

Meningo-encephalitis. — Following  convulsions,  monoplegia  or  hemi- 
plegia may  appear,  due  to  involvement  of  the  motor  area. 

Spinal. — In  rare  cases,  lancinating  pains  are  complained  of,  due  to 
involvement  of  the  spinal  roots. 

Chrome  Form. — Such  cases  have  been  described,  extending  over  a 
period  of  months,  in  which  remissions  lasting  weeks  and  months  have 
taken  place. 


TUBERCULOUS  MENINGITIS  823 

Diagnosis. — The  diagnosis  during  the  prodromal  period  may  be 
very  difficult;  although  the  vomiting,  severe  headache,  drowsiness, 
change  in  disposition,  and  irregular  pulse  and  respirations  should 
arouse  one's  suspicions  of  some  form  of  meningitis. 

An  absolute  diagnosis  of  tuberculous  meningitis  can  usually  be 
made  by  exammation  of  the  cerebrospinal  fluid,  which  also  enables 
one  to  differentiate  between  the  various  types  of  meningitis.  The 
fluid  removed  by  lumbar  puncture  is  imder  great  pressure,  and  is  at 
first  usually  clear  or  slightly  turbid,  later  opalescent  or  turbid,  or  may 
even  be  purulent  (owmg  to  mixed  infection).  There  is  generally  a 
relatively  slight  cellular  increase,  in  which  the  mononuclear  cells 
predominate.  As  the  spinal  fluid  becomes  secondarily  infected,  the 
polynuclear  elements  predominate. 

As  a  rule,  there  is  a  great  excess  of  globulin.  There  may  or  may 
not  be  a  reduction  of  Fehling's  solution,  depending  upon  the  type 
of  cells  that  predominate;  if  the  mononuclear  cells  are  in  excess  the 
solution  reduces,  whereas  if  the  pohiiuclear  elements  increase  this 
reducing  power  diminishes. 

An  absolute  diagnosis  of  tuberculous  meningitis  can  only  be  made 
by  isolatuig  the  bacilli  from  the  spinal  fluid.  This  can  be  accom- 
plished in  practically  every  case,  although  it  usually  requires  a  long, 
diligent  search.  Repeated  punctiues  are  frequently  necessary.  The 
technic  of  the  procedure  is  as  follows : 

From  10  to  20  c.c.  of  spinal  fluid  are  put  in  an  ice  chest  and  allowed 
to  stand  twelve  to  twenty-four  hours,  during  which  time  a  fine  fibrinous 
coagulum,  resembling  a  spider  web,  usually  forms.  This  coagulum 
is  carefully  floated  out  upon  a  glass  slide,  then  teased  out,  and  finally 
stained  for  the  tubercle  bacillus.  In  other  cases  centrifuging  may  be 
necessary,  and  a  preparation  made  of  the  precipitate.  In  stifl  other 
cases  superimposing  drop  upon  drop,  obtamed  by  scrapmg  the  side 
of  the  test-tube  with  a  platinum  loop,  may  give  the  desired  result. 
Should  it  be  unsuccessful,  then  an  intraperitoneal  inoculation  of  the 
spinal  fluid  should  be  made  in  a  guinea-pig,  in  which  case  the  diagnosis 
wfll  be  confirmed  only  after  the  death  of  the  patient. 

In  addition  other  means  of  diagnosis  should  be  employed.  Tubercle 
bacifli  can  often  be  isolated  from  the  sputum.  Tuberculin  reactions 
— those  of  von  Pirquet,  of  Moro,  and  of  Monteau — assist  by  estab- 
lishing the  presence  or  absence  of  tuberculous  infection.  In  a  series 
of  cases  reported  by  Koch,  from  von  Phquet's  Clmic,  84  per  cent, 
gave  a  positive  reaction  durmg  the  second  week  before  the  child  died, 
dropping  to  65  per  cent,  in  the  last  week  of  the  Alness.  The  tuber- 
culous reaction  diminishes  during  the  last  stage. 

Other  evidences  of  tuberculosis  should  also  be  sought  for.  By  a 
physical  examination  enlarged  bronchial  glands  or  active  lung  foci 
may  be  determmed,  and  be  confirmed  by  the  .r-rays;  at  times  the 
primary  focus  of  infection  in  the  lungs  is  shown  by  the  a-rays,  and 
should  always  be  looked  for.  The  clinical  symptoms,  combined  with 
the  laboratory  findings,  usually  establish  the  diagnosis. 


824  THE  NERVOUS  SYSTEM 

Prognosis. — Tubei-culous  meningitis  is  almost  always  fatal.  There 
are,  however,  a  few  authentic  recoveries  recorded,  in  which  tubercle 
bacilli  were  present  in  the  spinal  fluid;  yet,  considering  the  length 
of  the  remissions,  it  is  necessary  to  keep  these  patients  under  obser- 
vation for  a  long  period  of  time  before  pronomicing  them  ciued. 

Prophylaxis. — The  child  should  be  carefully  guarded  against  am^ 
possible  tuberculous  infection.  This  is  considered  more  fully  in  the 
chapter  on  Tuberculosis.  If  it  becomes  infected,  then  the  greatest 
care  should  be  exercised  to  prevent  mental  excitement,  overexertion, 
and  to  protect  the  child  from  the  infections — measles  and  whooping- 
cough — which  so  frequently  precipitate  meningitis. 

Various  procedures  have  been  advised  for  the  treatment  of  this 
disease,  but  none  have  been  effectual.  Drainage  of  the  subarachnoid 
spaces,  also  ventricular  puncture,  have  been  suggested.  Irrigation 
of  the  spinal  canal  has  also  been  performed.  The  least  harmful  pro- 
cedure is  lumbar  puncture,  which  should  be  repeated  as  often  as 
necessary  for  the  relief  of  symptoms.  Improvement  usually  follows 
this  procedure,  but  death  ensues  later. 

Treatment. — Our  field  for  treatment  lies  in  prophylaxis;  since, 
after  the  disease  has  been  established,  the  treatment  can  be  only 
symptomatic. 


DISEASES   OF  THE   BRAIN. 

CEREBRAL   PALSIES. 

In  the  symptom-complex  of  cerebral  palsies  are  included  a  variety 
of  clinical  manifestations,  the  remams  of  former  cerebral  diseases, 
of  various  anatomical  lesions,  and  etiological  factors,  leaving  behind 
certain  permanent  anatomical  lesions  and  clinical  disabilities.  From 
a  single  symptom  it  is  impossible  to  make  a  definite  anatomical 
diagnosis. 

Etiology. — Cerebral  lesions  giving  rise  to  cerebral  palsies  may  occur 
as  follows: 

1.  Causes  Prior  to  Birth. — ^^Malformations  of  the  brain,  porenceph- 
alia, microcephalia,  and  cysts  are  frequently  associated  with  malfor- 
mations elsewhere  in  the  body,  as  in  the  kidneys,  heart,  etc.  Fright, 
anger,  sorrow,  or  trauma  may  give  rise  to  hemorrhage  or  thrombosis. 
Alcoholism  in  the  parents  is  of  some  importance;  also  syphilis  which 
leads  to  tissue  changes  about  the  vessels,  and  gives  rise  to  endarteritis. 

2.  Injuries  at  Birth. — Trauma  from  forceps,  asphyxiation  from  a 
long  and  difficult  labor,  or  premature  birth  may  all  bring  about  menin- 
geal hemorrhage.  Fsilally,  however,  intra-uterme  trauma  or  maternal 
s^-philis  precipitates  premature  birth. 

.3.  Causes  After  Birth. — Dhect  trauma  to  the  head  may  cause 
hemorrhages.      The    most    common    postnatal    cause,    however,    is 


CEREBRAL  PALSIES  '  825 

encephalitis  secondary  to  acute  infections,  such  as  measles,  scarlet 
fever,  whooping-cough,  typhoid  fever,  tonsillitis,  chorea,  and  endo- 
carditis. 

We  distinguish  two  main  types  of  cerebral  palsies: 
(1)  Infantile  hemiplegia.     (2)  Cerebral  diplegia,  or  Little's  disease. 
'In  general  it  may  be  said  that  a  difficult  labor,  premature  labor,  and 
asphyxia  give  rise  to  cerebral  diplegia,  whereas  infections  lead  to 
hemiplegia. 

Pathological  Anatomy. — The  initial   lesions   are:      (1)  hemorrhage; 

(2)  embolism;  (3)  thrombosis;  (4)  acute,  and  sometimes  chronic, 
encephalitis. 

At  a  later  stage,  and  as  a  result  of  these  initial  lesions,  the  following 
conditions  are  frequently  seen:     (1)  porencephalia;  (2)  microgyria; 

(3)  cysts;  (4)  patches  of  glial  and  connective-scar  tissue;  (5)  local- 
ized sclerotic  patches  (tuberous  sclerosis) ;  (6)  unilateral  sclerosis  of  a 
portion  of  one  cerebral  hemisphere — cerebral  atrophy. 

When  the  condition  is  the  result  of  an  inflammatory  process,  the 
meninges  are  usually  thickened. 

Infantile  Hemiplegia. — This  form  of  palsy  usually  comes  on  after 
birth,  either  in  consequence  of  a  syphilitic  taint  or  an  encephalitis, 
but  may  occur  either  before  or  during  birth.  After  the  fifth  year  it 
is  rare. 

Symptoms. — Although  prodromal  symptoms,  such  as  headache, 
fever,  vomiting,  and  general  malaise  may  precede  the  onset,  yet  the 
disease  usually  sets  in  suddenly  with  fever,  convulsions,  and  sometimes 
coma,  followed  by  hemiplegia,  which,  however,  may  not  appear,  for 
a  week  or  more.  Convulsions  are  usually  on  the  same  side  as  the 
paralysis. 

The  paralysis  in  the  beginning  is  a  flaccid  one,  involving  the  face — 
its  muscles  and  inferior  branches — and  the  arm  and  leg. 

After  eight  to  ten  days  the  acute  stage  subsides,  and  the  paralysis 
gradually  recedes,  and  becomes  spastic.  Improvement  takes  place, 
especially  in  the  face  and  leg.  The  face  muscles  may  almost  wholly 
recover  merely  showing  weakness  by  mimetic  and  emotional  con- 
tortions. The  leg,  too,  may  almost  wholly  recover,  for  on  exammation 
the  only  evidence  of  the  former  lesion  may  be  exaggerated  reflexes. 

The  arm  becomes  spastic,  and,  in  less  favorable  cases,  the  leg  like- 
wise. The  position  that  the  arm  assumes  is  characteristic.  The 
upper  arm  is  adducted,  the  forearm  flexed  and  pronated,  the  wTist 
flexed,  the  thumb  adducted,  and  the  fingers  flexed  upon  it.  The  leg, 
too,  shows  a  spastic  condition;  it  is  rotated  inward,  and  extended  at 
the  hip-  and  knee-joints,  with  plantar  flexion  of  the  foot — pes  cavus. 
In  walking  the  leg  is  dragged,  and  there  is  a  circumduction  like  that 
seen  in  an  adult  hemiplegic.  When  it  w^alks  the  child  makes  accom- 
panying movements  of  the  arm  by  raising  it,  and  the  faster  the  patient 
walks  the  higher  the  arm  is  lifted. 

Although  the  reflexes  may  be  absent  at  the  onset,  they  are  always 
exaggerated.     The  Babinski,   Oppenheim,   and  Gordon  reflexes  are 


826  THE  NERVOUS  SYSTEM 

present.  Ankle  and  patella  clonus  may  also  be  present.  Aphasia 
may  appear  associated  with  either  a  right  or  left-sided  lesion,  but  it 
usually  soon  disappears.  Ataxia  and  intention  tremors  accompanied 
by  voluntary  movements  are  present,  also  involuntary,  posthemiplegic, 
choreiform,  and  athetoid  movements,  as  a  result  of  which  muscular 
hypertrophy  takes  place. 

Sensory  disturbances  and  cranial  nerve  palsies  are  rare.  At  times 
there  is  atrophy  of  the  optic  nerve,  hemianopsia,  and  rigid  pupils, 
the  latter  usually  associated  with  syphilis. 

Trophic  disturbances  of  the  muscles,  skin,  and  especially  of  the 
bones,  are  common.  The  skin  is  cool  and  livid.  There  is  muscidar 
atrophy  from  lack  of  f miction.  The  changes  in  the  bones  are  most 
important,  the  growth  of  the  cranial  bones  bemg  sometimes  so  affected 
as  to  produce  marked  asymmetry  of  the  head  arid  face.  The  long 
bones  are-  especially  involved,  there  is  shortening  of  the  affected  arm 
and  leg,  and  the  growth  of  the  bone  is  affected,  especially  its  length, 
and  the  shortening  is  more  at  the  distal  than  the  proximal  end.  The 
circumference  is  also  lessened,  especially  in  the  central  portion. 

Epilepsy  is  a  frequent  complication,  developing  in  more  than  one- 
half  the  cases.  After  the  initial  convulsion,  the  patient  may  remain 
free  for  days,  months,  or  years  before  epileptic  seizures  appear. 

The  mental  development  of  the  child  may  be  normal;  usually, 
however,  some  distiu-bance  of  intelligence  is  observed,  and  this  may 
vary  from  mere  feeble-mindedness  to  absolute  idiocy. 

Cerebral  Diplegia — Spastic  Paraplegia — Little's  Disease. — This  type 
usually  occurs  either  before  birth  or  durmg  delivery  as  the  result  of 
a  difficult  labor.  Asphyxia  neonatorum  is  the  most  frequent  cause  for 
hemorrhage.  Trauma  from  forceps  and  hereditary  sj^philis  are  like- 
wise important. 

Symptoms. — In  severe  cases  the  disease  is  usually  noticed  soon  after 
birth,  the  child's  body  and  extremities,  especially  the  legs,  bemg  rigid 
and  spastic.  In  less  severe  cases  this  may  not  be  observed  until  the 
time  when  the  child  should  begin  to  walk,  when,  on  puttmg  it  on  its 
feet,  marked  rigidity  of  the  extremities  is  noticed.  The  thighs  are 
rotated  inward,  the  knees  cross  and  touch  from  contractions  of  the 
adductors,  and  the  child  stands  upon  its  toes  with  its  foot  in  complete 
plantar  flexion.  The  contractions  m  the  thigh  mvolve  the  adductors 
and  flexors,  whereas  the  gastrocnemei  are  most  involved  in  the  lower 
leg.  The  arms  are  less  affected,  although  the  spasticity  may  be 
marked. 

When  the  upper  extremities  are  involved,  the  arms  are  adducted  to 
the  body,  the  elbows  are  bent,  the  -^Tists  flexed,  the  thumbs  adducted, 
and  the  fingers  flexed  upon  them. 

The  muscles  of  the  body  generally  are  involved,  giving  rise  to 
lordosis,  k^^hosis,  and  scoliosis. 

The  gait  is  quite  characteristic — the  so-called  "scissors  gait."  On 
attempting  to  walk  the  legs  are  crossed,  the  knees  are  pressed  together 
and  cannot  be  dra\vai  apart,  and  the  child  walks  on  its  toes. 


CEREBRAL  PALSIES 


827 


Tremors  and  ataxia  are  common.  Choreiform  and  athetoid  move- 
ments are  less  frequent  in  this  form  than  in  the  hemiplegia  tj'pe. 

The  deep  reflexes  of  the  involved  area  are  greatly  exaggerated. 
Ankle-  and  patellar  clonus  are  present,  as  well  as  the  Babinski,  Oppen- 
heim,  and  Gordon  reflexes.  On  the  other  hand,  the  extremities  may 
be  so  rigid  that  no  reflexes  can  be  elicited.  Trophic  disturbances  of 
the  skin,  muscle,  and  bones  are  usually  not  extensive. 


Fig.  !S4. — reeble-minded,  spastic  para- 
plegia; male,  aged  six  years. 


Fig.  So.- 


-Idiocy,  spastic  diplegia;  male, 
aged  four  years. 


There  may  be  cranial  nerve  palsies,  nystagmus,  strabismus,  atrophy 
of  the  optic  nerve,  and  inequality  of  the  pupils.  The  face  may  be 
involved,  and  have  a  mask-like  appearance.  Dysarthria  and  brady- 
lalia are  common,  and  are  usually  accompanied  by  impairment  of 
intellect.  Esophageal  spasm  is  sometimes  observed,  and  causes 
difficulty  in  swallowing. 

Convulsions  m  the  first  few  days  after  bhth  are  common;  but 


828  THE  NERVOUS  SYSTEM 

epilepsy,  which  develops  later,  is  not  as  frequent  as  in  other  types  of 
palsy. 

The  mental  development  of  the  child  may  be  normal,  although 
there  is  usually  a  defect  in  mentality  varying  from  feeble-mindedness 
to  idiocy. 

Diagnosis. — The  diagnosis  of  cerebral  infantile  palsies  is  piu-ely  a 
clinical  one,  and  can  be  made  only  by  considering  the  history  with 
special  reference  to  the  question  whether  or  not  the  palsy  is  progres- 
sive, and  there  are  any  progressive  brain  symptoms. 

Cerebral  hemiplegia,  setting  in  acutely  as  an  encephalitis,  must 
be  differentiated  from  meningitis,  infectious  fevers,  infantile  eclampsia, 
and  poliomyelitis.  The  differentiation  from  the  latter  disease  is  no 
longer  of  much  importance,  for  we  now  know  that  both  the  cerebral 
and  spinal  forms  may  coexist  in  the  same  patient,  being  known  as 
encephalopoliomyelitis . 

Cerebral  palsies  must  be  differentiated  from  brain  tumors  of  slow 
growth,  from  cerebral  syphilis,  multiple  sclerosis,  hydrocephalus,  and 
Friedreich's  ataxia. 

Prognosis. — Improvement  may  go  on  for  years.  The  arms  may 
almost  completely  recover,  except  for  a  slight  permanent  spasticity. 
Improvement  also  takes  place  in  the  lower  extremities,  for  these  chil- 
dren learn  to  walk,  even  if  tardily;  the  mental  calibre,  too,  often 
somewhat  improves.  They  are  always  predisposed  to  intercurrent 
infectious  diseases,  to  which  they  readily  succumb.  In  the  hemi- 
plegic  form  death  may  take  place  during  the  initial  stage.  Improve- 
ment is  usually  as  great  as  in  the  diplegias. 

Treatment. — This  is  purely  symptomatic,  in  order  to  maintain  the 
proper  nutrition  of  the  parts  involved,  and  depends  upon  the  intelli- 
gence of  the  child,  the  extent  of  the  paralysis,  and  the  amount  of 
deformity. 

The  galvanic  current  should  be  applied  to  the  affected  muscle. 
Hydrotherapeutic  measures,  such  as  warm  baths,  tend  to  relax  the 
muscle  spasm.  Massage,  combined  with  passive  movements,  gym- 
nastic exercises,  and  Frenkel's  movements  are  of  special  benefit  in 
cases  in  which  there  is  not  too  great  impairment  of  the  mentality. 

Braces  may  be  necessary  to  prevent  contractures,  and  various 
orthopedic  operations — tenotomy  and  tendon  transplantation — have 
been  devised  for  their  relief. 

Trephining  of  the  skull  with  removal  of  the  primary  foci  has  been 
performed  for  the  relief  of  epilepsy.  The  mental  training  of  the  child 
should  not  be  neglected. 

IDIOCY. 

Synonyms. — ^Mental  Deficiency — Imbecility — Feeble-mindedness. 

Children  who  have  mental  diseases  may  be  divided  into  two  classes: 
those  who  have  physical  defects  in  addition  to  the  mental  condition, 
and  those  in  whom  there  are  no  physical  defects. 

It  is  impossible  to  make  a  sharp  differentiation  between  the  various 


IDIOCY 


829 


types  of  mental  defects  in  children,  as  the  different  forms  blend  into 
one  another;  but  cretinism,  Mongolian  idiocy,  and  amaurotic  family 
idiocy  are  types  easily  recognized. 

Imbecility  and  feeble-mindedness  are  terms  applied  to  the  minor 
forms  of  idiocy  in  which  there  is  no  extensive  cerebral  lesion.  The 
backward  child  should  not  be  placed  in  this  class,  for  its  retarded 
mental  development  is  often  due  to  some  abnormal  physical  condition 
which  can  be  corrected,  such  as  defective  sight  or  hearing. 

Etiology. — Idiocy  may  be  either  congenital  or  acquired.  In  the 
majority  of  cases  which  present  physical  defects,  idiocy  is  congenital, 
and  may  be  associated  with  defective  brain  development,  as  in  poren- 
cephalia and  agenesis  corticalis,  or  with  lack  of  development  of  the 
brain  as  a  whole. 

Another  class  of  cases  is  associated  with  internal  or  external  hydro- 
cephalus,  and  microcephalic  children  furnish  a  certain  number   of 


Fig.  bG. — Idiocy,  male,  aged  five  years. 

these  cases.  Consanguinity,  injuries  at  birth,  and  syphilis  are  not 
uncommon  causes  of  idiocy  in  children,  and  in  many  cases  in  which 
paralysis  appears  there  is  a  history  of  meningeal  hemorrhage  or  cere- 
bral hemorrhage  of  traumatic  origin. 

Cretinism,  cerebrospinal  meningitis,  and  anterior  poliomyelitis  may 
also  give  rise  to  idiocy,  and  a  certain  proportion  of  epileptics  become 
idiots  as  a  result  of  brain  lesions  due  to  repeated  epileptic  seizures. 

As  a  rule,  mental  defects  unassociated  with  physical  abnormalities 
are  not  apparent  until  the  second  period  of  childhood,  melancholia, 
mania,  katatonia,  and  dementia  being  occasionally  observed  in  older 
children. 

Although  no  definite  time  limit  can  be  established  for  the  manifes- 
tation of  the  various  phases  of  mental  function,  yet  in  the  normal 
infant  there  should  be  evidences  of  control  of  the  senses  of  hearing  and 
sight  by  the  fourth  month,  later  appreciable  signs  of  memory,  percep- 


830  THE  NERVOUS  SYSTEM 

tion,  and  power  of  attention,  and  the  child  should  be  able  to  recognize 
objects  and  familiar  faces  and  be  able  to  express  pain  and  pleasure. 

At  nine  months  some  degree  of  understanding  should  be  manifested 
when  familiar  words  are  spoken,  and  at  this  age  the  normal  infant 
should  begin  to  imitate  spoken  words,  and  attempt  to  creep  about. 

When  any  of  these  functions  is  considerably  delayed,  the  child 
should  be  carefully  studied  in  order  to  determine  accurately  the  extent 
of  mental  impairment.  The  family  history  and  lives  of  the  parents 
should  be  investigated  for  some  possible  etiologic  factor,  and  an 
accurate  history  of  the  child's  life  from  birth  be  secured.  Special  note 
should  be  made  of  any  insanity,  alcoholism,  chorea,  or  hysteria  in 
the  family,  and  m  the  child's  history  convulsions  shortly  after  birth, 
injuries  at  birth,  eclampsia,  and  asphj-xia  are  important  points. 

Symptoms. — Both  mental  and  physical  symptoms  accompany 
idiocy,  although  an  idiot  may  resemble  a  perfectly  normal  child. 

Mental  Stigmata. — ^Mental  deficiency  is  rarely  suspected  in  early 
infancy,  except  in  the  case  of  the  ^Mongolian  idiot,  m  whom  we  find 
abnormality  of  the  features.  When  physical  defects  are  present, 
they  are  usually  noticed  before  mental  abnormality  is  suspected,  and 
in  these  cases  the  infant  is  brought  to  the  physician  because  it  cannot 
sit  up,  walk,  or,  perhaps,  talk  at  the  proper  time. 

Upon  examination  it  becomes  evident  that  the  child  has  no  control 
of  its  limbs;  saliva  usually  dribbles  from  its  mouth;  it  has  a  vacant 
stare,  or  moves  the  eyes  aimlessly,  taking  no  particular  notice  of  any- 
thing. The  eyes  should  always  be  examined  in  these  cases  to  determine 
whether  or  not  there  are  any  visual  defects,  such  as  microphthalmia, 
rederemia,  coloboma  hidis,  lesions  of  the  vitreous,  congenital  cataract, 
strabismus,  or  partial  or  central  blindness  of  central  origin. 

The  sense  of  hearing  may  be  defective  or  entirely  absent  from  con- 
genital or  acquired  causes,  and  in  idiots  there  is  always  imperfect 
development  of  the  senses  of  taste  and  smell.  The  appetite  is  usually 
ravenous,  but,  as  a  rule,  there  is  no  particular  preference  as  to  food. 
There  is  also  a  remarkable  degree  of  insensibility  to  pain,  heat,  and 
cold,  and  this  in  some  cases  may  be  so  great  that  bodily  injury,  and 
even  mutilations,  self-inflicted,  are  not  uncommon. 

Even  when  the  sight  is  perfect,  the  idiot  may  not  recognize  its 
mother,  shows  no  instmctive  understanding  of  the  nursmg  bottle., 
and  at  the  age  when  it  should  be  talking — one  to  two  years — utters 
strange  somids  and  shrill  cries,  and  makes  no  attempt  to  imitate 
spoken  words. 

At  the  age  of  tliree  or  foiu-  years,  most  cases  of  idiocy  can  be  recog- 
nized, for  the  children  do  not  talk,  their  vacant  expression  is  apparent 
to  all  but  the  mother,  they  are  unclean  in  their  habits,  in  defecating 
and  m-mating,  and  m  temperament  they  are  either  amiably  stupid, 
or  irritable,  excitable,  and  uncontrollable. 

Convulsions  are  not  rare  in  idiots,  and  in  the  majority  of  cases  they 
signify  the  presence  of  definite  organic  lesions  of  the  central  nervous 
system,  such  as  are  found  in  meningitic  and  sj-philitic  idiocy. 


IDIOCY  831 

Physical  Manifestations. — ^The  head  may  be  either  excessively  large 
(hydrocephalic)  or  very  small  (microcephalic).  The  hydrocephalic 
head  is  familiar  to  all,  with  its  rounded  ball-shape,  widest  at  the 
temples,  and  presenting  a  sharp  contrast  to  the  small  face  and  tiny 
features.  These  children  are  usually  dull  and  stupid,  but  not  irritable, 
and  they  have  a  timid,  shrinking,  and  sad  appearance. 

The  microcephalic  idiot  has  a  small  head  with  low  forehead,  a 
poorly  developed  occipital  prominence,  closed  fontanelles,  and  pre- 
maturely closed  and  ossified  sutures;  but,  strange  as  it  may  seem,  the 
small  skull  is  in  many  cases  independent  of  the  poorly  developed 
brain,  and  a  child  whose  skull  is  normal  may  have  a  microcephalic 
brain. 

Even  the  microcephalic  skull  is  usually  larger  than  the  brain 
requires,  for  there  is  a  lack  of  development  of  either  the  whole  brain 
or  of  the  occipital,  frontal,  or  parietal  lobes.  The  eyes  are  small, 
the  ears  project,  and  the  nose  and  lower  jaw  are  large,  so  that  the 
face  seems  quite  large  in  proportion  to  the  skull.  In  some  cases  the 
rest  of  the  body  may  appear  to  be  perfectly  normal,  while  in  others 
there  is  paralysis,  either  flaccid  or  spastic. 

True  microcephalic  idiots  are  obstinate,  vulgar,  and  brutal.  If 
the  brain  lesions  are  not  extensive,  they  sometimes  live  past  middle 
age,  but  the  hydrocephalic  infant  rarely  survives  until  the  end  of  the 
first  year. 

The  syphilitic  idiot  usually  presents  the  characteristic  signs  of 
syphilis,  such  as  the  bossed  skull,  saddle-nose,  Hutchinson's  teeth, 
rhagades,  and  congenital  deafness. 

Howe,  in  a  summary  of  517  cases  of  idiocy,  found  the  following 
physical  defects:  Deafness  in.  12,  blindness  in  21,  and  defects  in  the 
nose  or  mouth,  such  as  hare-lip  and  high  palatal  arch,  in  23  cases. 
The  condition  of  the  extremities  varies  in  the  different  types  of  idiocy. 
Howe  found  in  54  cases  of  this  same  series,  deformities  of  the  hands 
and  feet,  and  in  96  cases  there  was  paralysis  of  one  or  more  limbs. 

Many  hydrocephalic  infants  suffer  with  spastic  paraplegia,  the 
legs  being  aft'ected,  as  a  rule,  while  the  upper  extremities  are  but 
little  involved.  The  paralytic  idiot  has  either  hemiplegia  or  diplegia, 
and  contractures  may  become  quite  marked.  In  cretinism,  micro- 
cephalic idiocy,  and  syphilitic  idiocy  there  is  manifest  weakness  of 
all  the  extremities. 

Among  the  other  physical  peculiarities  which  idiots  occasionally 
present  may  be  mentioned  supernumerary  or  deficient  fingers  and 
toes,  asymmetry,  malformations,  congenital  dislocations,  ankyloses, 
and  numerous  minor  abnormalities. 

Diagnosis. — ^The  diagnosis  of  idiocy  is  a  matter  of  great  importance, 
but  can  be  positively  arrived  at  only  after  accurate  history  taking, 
which  in  many  instances  will  reveal  the  etiological  factor,  also  after 
careful  physical  examination  for  the  stigmata  of  degeneration,  and  an 
investigation  of  the  mentality  in  which  the  patient's  intelligence  is 
compared  with  that  of  a  normal  child  of  the  same  age.    jNIentality 


832  THE  NERVOUS  SYSTEM 

slightly  lower  than  normal  may  mean  merely  backwardness,  but  great 
deviations  from  the  normal  are  in  the  majority  of  cases  due  to  idiocy. 

Prognosis. — So  far  as  complete  recovery  is  concerned,  the  prognosis 
m  idiocy  is  unfavorable;  but  surprising  improvement  often  takes 
place,  so  that  a  case  must  not  be  pronounced  hopeless  unless  there 
is  some  congenital  defect  of  the  brain,  or  there  has  been  a  hemorrhage 
at  birth  which  caused  paraplegia  or  diplegia.  In  cases  which  follow 
menmgitis  or  encephalitis,  the  outlook  is  somewhat  better  than  in 
those  just  mentioned,  and  even  in  cretinism  and  syphilis  prompt 
therapeutic  measures  are  not  without  good  results. 

Treatment. — In  all  but  the  mildest  forms  of  idiocy  the  children  are 
far  better  off  in  institutions  which  will  educate  and  train  them  by 
special  methods  than  in  theh  own  homes;  and,  moreover,  they 
should  be  kept  apart  from  normal  children.  Special  schools  and 
training  are  necessary,  too,  for  the  backward  child,  if  the  best  results 
are  to  be  secured.  The  idiot  who  is  tractable  may  be  kept  at  home 
until  the  sixth  or  seventh  year  if  there  are  no  younger  children  to  whom 
he  may  set  a  bad  example. 

Moral  degenerates  and  vicious  and  unclean  idiots  should  be  placed 
in  institutions  just  as  soon  as  they  can  be  admitted.  The  problem 
of  the  mentally  deficient  child  is  an  economic  one,  and  experience  has 
proven  that  many  of  these  unfortunates  may  become  self-supporting 
instead  of  being  always  a  cost  to  the  family  or  the  State. 

AMAUROTIC   FAMILY   IDIOCY. 

This  disease,  which  was  first  described  by  Warren  Tay,  in  1881, 
and  later  given  its  name  by  Sachs,  of  New  York,  is  not  a  rare  one. 
It  is  characterized  by  arrested  cerebral  development,  by  blindness, 
and  by  changes  in  the  macula  lutea,  together  with  progressive  impair- 
ment of  the  functions  of  the  muscles.  The  affection  shows  a  marked 
predilection  for  the  Hebrew  race,  nearly  all  of  the  recorded  cases 
having  occurred  among  Jewish  people. 

Etiology. — The  etiology  is  most  obscure,  and  it  has  not  been  defi- 
nitely determined  whether  the  arrested  development  and  degeneration 
are  due  to  antenatal  or  postnatal  causes.  ^lany  observers  believe 
the  affection  to  be  toxic  in  origm,  and  it  has  also  been  attributed  to 
syphilis  and  alcoholism  in  the  parents.  It  is  not  uncommon  for  two, 
tliree,  or  four  children  in  the  same  family  to  be  affected. 

Pathology. — Postmortem  investigations  have  sho^^Ti  degeneration 
of  the  ganglion  cells  throughout  the  entire  nervous  system.  The 
cellular  structures  lose  their  identity,  their  nuclei  being  scarcely  demon- 
strable, and  the  protoplasm  markedly  degenerated.  Blindness  in 
these  cases  is  due  to  degeneration  of  the  ganglion  cells  of  the  retina 
and  of  the  fibers  of  the  optic  nerves  and  tracts. 

Symptoms. — The  infant  is  apparently  normal  at  birth,  and  may 
remain  so  until  the  sixth,  or  even  the  tenth  month,  when  the  parents 
usually  notice  that  it  makes  no  progress  in  development.     At  this 


MONGOLIAN  IDIOCY  833 

age  the  child  does  not  hold  up  its  head,  moves  about  very  little,  takes 
no  interest  in  its  surroundings,  and  does  not  even  follow  objects  with 
its  eyes.  But,  unless  an  ophthalmic  examination  is  made,  blindness 
may  not  be  suspected,  although  the  eyes  have  a  peculiar  and  fixed 
stare.    Nystagmus  may  be  present  but  is  not  pathognomonic. 

The  child  now  begins  to  retrograde,  instead  of  progressing,  and  by 
the  end  of  the  first  year  optic  atrophy  and  paresis  may  be  complete. 
The  muscles  are  absolutely  without  power,  and  the  little  one  can 
neither  sit  up  nor  hold  up  its  head.  At  first  there  is  flaccidity,  later 
rigidity  and  spasticity  of  the  muscles,  and  occasionally  convulsions. 

Mental  retrogression  is  also  noticeable,  and  the  child  fails  to  recog- 
nize familiar  objects  and  faces,  but  is  unusually  susceptible  to  sounds, 
starting  violently  at  each  sudden  noise,  such  as  the  slamming  of  a 
door  or  clapping  of  the  hands.  Eventually  it  becomes  dull,  apathetic, 
totally  indifi^erent  to  its  surroundings,  and  has  no  power  to  change  the 
position  of  its  limbs.  Progressive  emaciation  renders  the  child  help- 
less, and  a  pitiable  object  of  mere  skin  and  bone. 

In  some  cases  swallowing  becomes  impossible,  and  gavage  is  neces- 
sary. Death  usually  occurs  in  about  a  year  after  the  onset,  and  is 
due  to  marasmus,  exhaustion,  or  hypostatic  pneumonia. 

Prognosis. — The  disease  comes  on  slowly,  and  its  course  is  marked 
by  gradual  but  progressive  mental  and  physical  degeneration,  and  an 
invariably  fatal  termination. 

Diagnosis. — As  a  rule  the  diagnosis  is  readily  made  from  the  signs 
and  symptoms.  The  findings  on  ophthalmic  examination  are  pathog- 
nomonic. 

Treatment. — Treatment  is  never  curative,  but  under  judicious 
management  the  life  of  these  infants  may  be  prolonged  for  a  year  or 
more,  although  death  is  inevitable. 

MONGOLIAN    IDIOCY. 

The  Mongolian  type  of  idiocy  occurs  only  in  the  Caucasian  race, 
and  is  characterized  chiefly  by  a  Mongolian,  or  Chinese,  cast  of  face, 
also  by  a  microcephalic  skull  and  retarded  growth  of  the  bones. 

Etiology. — This  form  of  idiocy  is  congenital,  and  in  the  majority 
of  cases  it  will  be  found  that  both  parents  were  past  middle  age  when 
the  child  was  born,  but  nothing  further  is  known  of  its  etiology. 
The  disease  appears  with  equal  frequency  in  all  classes  of  society. 
There  is  usually  but  one  case  in  a  family. 

Pathology. — The  brain  is  smaller  and  lighter  in  weight  than  normal, 
the  fissures  are  defective,  and  there  is  evidence  of  faulty  development 
of  the  cortex.  Usually  there  are  abnormalities  of  the  palate,  ears, 
and  fingers.  Malformations  of  the  heart,  such  as  incomplete  ventricu- 
lar septum  and  patent  ductus  arteriosus,  are  not  micommon,  although 
malformations  of  other  viscera  are  rare. 

Symptoms. — In  early  infancy,  the  facial  expression  and  backward- 
ness in  physical  development  are  the  only  noticeable  signs.  The 
53 


834 


THE  NERVOUS  SYSTEM 


Fig.  87. — Mongolian  idiocy;   child  aged  twenty  months. 


Fig.  88. — Mongolian  idiocy;  patient  aged  nine  months. 


MULTIPLE  NEURITIS  835 

head  is  flattened  from  before  backward,  the  fontaneUes  remain  open 
longer  than  usual,  th^nose  is  broad  and  flat,  and  the  eyes  are  more 
widely  apart  than  normal,  are  prominent,  and  slant  obliquely,  so  that 
the  palpebral  fissures  extend  upward  and  elevate  the  outer  canthus. 

The  peculiarities  of  the  face  in  these  cases,  together  with  mouth 
breathing  and  the  abnormally  large  tongue  which  protrudes  from  the 
open  mouth,  often  make  one  suspect  cretinism;  but  the  skin  is  soft 
and  velvety  in  the  early  stages,  and  the  hair  neither  dry  nor  brittle. 

Adenoids  are  sometimes  thought  of  as  a  cause  of  the  mouth  breath- 
ing; but  this  is  due  to  narrowing  of  the  nasopharyngeal  vault  pro- 
duced by  anteroposterior  narrowing  of  the  skull  and  prominence  of 
the  upper  cervical  vertebrae,  all  of  which  can  readily  be  appreciated 
by  making  an  examination  for  adenoids.  The  hands  are  short,  the 
little  finger  is  also  short,  and  frequently  curves  inward  over  the  ring 
finger.  Abnormalities  of  the  bones  of  the  hands  and  wrists  are  demon- 
strable by  ;r-ray  examination. 

The  muscles  of  the  body  are  flabby,  and  the  joints  all  show  evidences 
of  preternatural  mobility.  Growth  is  very  slow,  and  mental  develop- 
ment markedly  retarded.  Dentition  is  delayed,  the  teeth  usually 
not  appearing  until  the  fourth  or  fifth  year  when  the  child  can  walk 
and  talk. 

Prognosis. — There  are  mild,  moderate,  and  severe  cases  of  Mongolian 
idiocy.  The  severe  cases  usually  die  in  early  childhood  and  before 
they  are  three  years  old;  those  moderate  in  degree  may  live  past 
puberty,  and  do  fairly  well  in  institutions;  while  a  few  of  the  mild 
type  gradually  improve  mentally  until  they  show  a  fair  amount  of 
intelligence,  and  may  reach  adult  life. 

Diagnosis. — The  facial  expression  of  the  Mongolian  idiot  is  so 
characteristic  that  a  mistake  in  diagnosis  is  most  unlikely.  Other 
.  diagnostic  points  are  the  shortness  and  incurvation  of  the  little  finger 
and  the  extreme  flexibility  of  the  joints.  Mongolian  idiocy  may  some- 
times be  mistaken  for  cretinism;  but  thyroid  therapy  has  no  effect 
on  the  Mongolian  idiot,  and  close  examination  of  these  children  reveals 
other  differential  points,  such  as  the  slanting  eyes,  the  condition  of 
the  hair  and  skin,  and  the  absence  of  m^^cedema. 

Treatment. — There  is  no  medical  treatment  that  exerts  any  influence 
on  the  aft'ection.  Massage,  fresh  air,  and  careful  regulation  of  the 
diet,  combined  with  the  best  possible  hygienic  conditions,  are  of 
benefit  in  maintaining  the  child's  health  and  strength. 


DISEASES   OF  THE   NERVES. 

MULTIPLE    NEURITIS. 

Multiple  neuritis,  except  the  postdiphtheritic  form,  is  a  very  rare 
disease  in  childhood.     It  is  either  secondary  to  certam  infections, 


836  THE  NERVOUS  SYSTEM 

diseases  and  poisons,  or  may  occur  as  an  idiopathic  disease.  Its  most 
frequent  cause  is  diphtheria,  which  gives  rise  to  some  form  of  neuritis 
in  from  5  to  12  per  cent,  of  all  cases.  In  addition,  multiple  neuritis 
has  developed  after  typhoid  fever,  and,  more  rarely,  after  scarlet 
fever,  measles,  malaria,  influenza,  erysipelas,  chicken-pox,  pneumonia, 
and  tonsillitis.  Of  the  poisons,  alcohol,  phosphorus,  arsenic,  and  lead, 
all  produce  neuritis,  but  these  forms  are  seldom  seen  in  childhood. 

Diphtheritic  Paralysis. — Diphtheritic  paralysis  is  a  frequent  com- 
plication of  diphtheria,  and  is  estimated  variously  at  between  5  to 
12  per  cent,  of  all  cases.  This  proportion  is  thought  to  have  been 
increased  by  the  use  of  antitoxin.  It  must  be  remembered,  however, 
that  the  death  rate  of  the  disease  has  dimmished,  and  that  many 
children  who  previously  would  have  died  from  a  severe  form  of  diph- 
theria are  now  saved  by  antitoxin,  and  these  cases  may  later  show 
paralysis.  Unless  the  serum  is  administered  very  early  it  will  have 
little  effect,  as  it  does  not  seem  to  give  the  same  protection  to  the 
nervous  system  as  to  the  rest  of  the  body.  Neither  does  the  severity 
of  the  infection  modify  greatly  its  frequency;  for,  although  most 
commonly  observed  in  the  severe  types,  yet  it  often  occurs  after  mild 
infections.  In  fact,  the  paralysis  may  sometimes  be  the  first  sign  of 
diphtheria,  the  throat  symptoms  having  been  so  mild  as  to  have 
escaped  notice.  Paralysis  usually  sets  in  two  to  three  weeks  after 
the  disease  has  subsided,  although  it  may  develop  during  its  course. 

Pathological  Anatomy. — The  most  extensive  pathological  changes 
are  found  in  the  peripheral  nerves.  These  changes  may  be  both 
interstitial  and  parenchymatous,  the  latter  being  the  most  pronounced. 
There  are  degeneration  of  the  parenchyma  and  mflammation  and 
proliferation  of  connective-tissue  cells  which  cause  cylindrical  and 
fusiform  swellings  on  the  trunks  of  the  nerves,  appearing  most  fre- 
quently on  the  smaller  nerves  in  the  muscles  and  skin.  Similar  degen- 
erations have  been  observed  in  the  cranial  nerves,  as  well  as  inflam- 
matory changes  in  the  gray  matter  of  the  spinal  cord,  and  hemorrhages 
and  hyperemia  in  the  white  matter  and  spinal  ganglia. 

Sym.ptoms. — ^The  paralysis  is  quite  variable.  It  may  either  be 
limited  to  isolated  groups  of  muscles  or  more  generalized,  involving 
numerous  spinal  and  cerebral  nerves. 

Three  different  forms  of  the  affection  may  be  distinguished.  In 
the  early  and  milder  form,  paralysis  of  the  soft  palate  develops  first, 
often  making  its  appearance  during  the  acute  stage  of  the  disease 
following  the  angina;  or  it  may  not  appear  until  one  to  three  weeks 
have  elapsed.  The  speech  becomes  nasal  in  tone,  and  unintelligible. 
On  attempting  to  swallow  fluids,  some  is  regurgitated  through  the 
nose,  and  the  ingestion  of  solid  food  is  markedly  impeded.  Upon 
examination  the  soft  palate  is  seen  to  be  flaccid,  immobile  on  phonation, 
and  exhibiting  with  difficulty  a  reaction  of  degeneration.  Most 
frequently  there  is  anesthesia  of  the  mucous  membranes,  with  corre- 
spondin.g  absence  of  the  pharyngeal  reflex. 

The  paralysis  may  extend,  and  involve  the  deep  pharyngeal  and 


MULTIPLE  NEURITIS  837 

laryngeal  muscles.  In  consequence  of  the  failure  of  the  epiglottis  to 
close  during  deglutition,  of  the  anesthesia  of  the  mucous  membranes, 
and  of  the  regurgitation  of  food  through  the  nose,  there  is  great 
danger  of  aspiration  of  food  into  the  larynx,  giving  rise  to  fatal  bron- 
chopneumonia. With  involvement  of  the  recurrent  laryngeal  nerve 
there  is  hoarseness,  or  even  aphonia. 

The  vagus  fibers  supplying  the  heart  may  be  suddenly  affected  and 
cause  a  slow  pulse  (Pare),  or,  more  frequently,  arrhythmia  and  a 
rapid  pulse  rate,  due  to  paralysis  of  the  depressor  fibers.  Sudden 
death  may  ensue  from  this  cause.  In  other  cases  the  paralysis  may 
extend  to  the  eyes,  involving  bilaterally  the  ciliary  muscles,  causing 
inability  to  accommodate  the  eye,  to  read,  or  to  do  any  fine  work. 
The  reaction  to  light  and  to  accommodation  is,  however,  usually 
present.  Other  ocular  palsies  are  rare.  The  abducens  paralysis  is 
the  most  frequent;  the  oculomotor  or  trochlear  the  least  common. 
The  deep  tendon  reflexes  of  the  lower  extremities  may  be  lost  early  in 
the  disease.  In  a  few  cases  they  may  be  exaggerated  with  an  ankle- 
clonus. 

In  the  second  form — the  more  severe  type — the  involvement  is 
more  general,  extending  to  the  extremities  either  as  ataxia  or  as  true 
palsy  with  sensory  disturbances.  Ataxia  appears  about  foiu*  weeks 
after  the  paralysis  of  the  soft  palate.  The  gait  becomes  ataxic,  and 
Romberg's  sign  can  be  elicited.  The  deep  reflexes  are  abolished,  but 
in  this  form  there  is  no  paralysis  in  the  extremities;  in  fact,  the 
muscular  strength  may  be  perfectly  normal.  Paresthesias  are  com- 
plained of;  but  sensory  disturbances,  except  loss  of  muscle  sense,  are 
usually  not  pronounced. 

In  the  third,  or  most  severe  form,  there  are  extensive  atrophic 
flaccid  palsies  with  a  positive  reaction  of  degeneration.  The  muscles 
of  the  neck,  the  trunk,  the  intercostals,  and  the  diaphragm  may  like- 
wise be  involved.  Paralysis  of  the  plu-enic  nerve  gives  rise  to  cyanosis 
and  severe  dyspnea  which  may  suddenly  cause  death.  The  breathing 
becomes  Cheyne-Stokes  in  type,  accompanied  by  rapidly  increasing 
edema  of  the  lungs.  This  is  the  most  common  cause  of  death,  the 
mortality  being  76  per  cent,  in  33  cases  collected  by  Ross. 

A  facial  palsy  has  also  been  observed;  sensory  disturbances  are 
quite  marked;  hyperesthesias  and  anesthesias  are  extensive.  Bladder 
and  rectal  disturbances  are  rarely  present.  Trophic  disorders  of  the 
skin  may  appear.  In  grave  cases,  marked  mental  depression  has 
been  observed. 

Course  and  Prognosis. — The  course  of  the  disease  is  usually  a  favorable 
one,  and  ends  in  complete  recovery.  Paralysis  of  the  vagus  and  phrenic 
nerves,  aspiration  pneumonia,  and  general  inanition  are  to  be  feared, 
and  may  be  rapidly  fatal;  but  all  danger  to  life  is  generally  past  after 
six  to  eight  weeks.  The  paralysis  of  the  soft  palate  and  accommo- 
dation recedes,  and  at  the  end  of  three  or  fom*  months  the  symptoms 
have  usually  all  cleared  up.  Occasionally  some  remains  of  the 
paralysis,  especially  of  the  extremities,  will  persist  for  from  eight 


838  THE  NERVOUS  SYSTEM 

months  to  a  year.  Complications,  such  as  nepln-itis  and  endocarditis, 
make  the  prognosis  more  grave. 

Treatment. — In  the  majority  of  cases  of  postdiphtheritic  paralysis, 
the  treatment  consists  of  general  tonics  and  palliative  measm-es. 
When  the  paralysis  has  progressed  beyond  simple  paralysis  of  the 
soft  palate,  absolute  rest  in  bed  should  be  ordered,  and  all  possible 
strain  upon  the  heart  prevented.  The  paralysis  may  be  so  extensive, 
and  the  danger  of  aspirating  food  mto  the  larynx  so  great,  as  to  neces- 
sitate feeding  by  gavage.  The  tube  can  be  passed  either  through  the 
mouth  or  the  nose.  Usually  from  8  to  10  ounces  of  food  can  be  given 
at  intervals  of  four  to  six  hours.  If  sufficient  nourishment  cannot  be 
administered  in  this  manner,  and  the  nutrition  suffers,  nutritive 
enemata  may  be  required.  Cracked  ice  should  be  given  to  relieve 
the  thirst. 

'  Medication. — Of  drugs,  strychnine  is  the  most  beneficial.  It  should 
be  administered  hypodermically  at  tln-ee-hour  intervals  in  doses  of 
3-g- 0^  of  a  gram  for  a  one-  to  two-year-old  child ;  from  -jw^  to  ytw  o^  ^ 
gram  for  a  two-  to  four-year-old  child;  from  yi-g-  to  y^-jj-  of  a  grain 
after  the  fourth  year.  If  strychnine  can  not  be  used  hypodermically, 
tincture  of  nux  vomica  may  be  given  in  corresponding  doses.  For 
rapid  heart  action  and  restlessness,  small  doses  of  tincture  of  strophan- 
thiis  combined  with  codem  are  indicated.  To  ward  off  tln-eatened 
cardiac  paralysis,  morphine  should  be  administered  hypodermically 
together  with  strychnine.  When  respiratory  paralysis  seems  imminent, 
artificial  respiration  should  be  instituted  together  with  the  givmg  of 
strychnine.  In  these  severe  cases,  large  doses  of  diphtheria  antitoxin 
have  appeared  to  have  some  beneficial  results. 

In  the  acute  stage  all  hydrotherapeutic  measures  are  contraindi- 
cated.  When,  however,  the  paralysis  begins  to  recede,  electricity, 
massage,  and  mechanotherapeutical  procedures  should  be  begun. 
Mild  galvanic  stimuli  should  be  applied  to  the  extremities  and  the 
soft  palate.  Frenkel's  exercises  should  not  be  begun  vmtil  after  the 
heart  has  fully  recovered. 

Midtiple  Neuritis,  Postinfectious  (Non-diphtheritic). — Other  infec- 
tions which,  as  we  have  seen,  may  give  rise  to  paralysis,  are  typhoid 
fever,  m  rare  cases  scarlet  fever,  measles,  influenza,  malaria,  erysip- 
elas, chicken-pox,  pneumonia,  tonsillitis,  tuberculosis,  and  syphilis. 
Neuritis  following  these  mfections  is  characterized  by  paraplegia, 
either  limited  to  the  peroneal  group  of  muscles  or,  in  some  cases,  to 
the  thigh,  or  it  may  extend  to  the  arms,  giving  rise  to  paralysis  of 
both  arms  and  legs,  in  which,  however,  there  is  no  predilection  for 
the  group  of  muscles  supplied  by  the  radial  nerve. 

Palsies  of  the  vagus,  so  characteristic  of  the  diphtheritic  form,  rarely 
occur.  As  the  disease  progresses  in  the  peroneal  group  of  muscles, 
there  is  resulting  weakness  which  subsequently  produces  foot-drop. 
On  walking  there  is  the  typical  "steppage-gait."  The  paralysis  may 
be  confined  to  this  group  of  muscles  or  may  extend  to  the  thighs  and 
arms.     Involvement  of  the  muscles  of  the  trunk  is  rare.     There  is 


FACIAL  PARALYSIS  839 

resulting  loss  of  reflexes,  both  superficial  and  deep,  in  the  involved 
-area,   a  positive  reaction  of  degeneration,    and  muscular   atrophy. 
Sensory   disturbances    are   marked.      Hyperesthesia    and    anesthesia 
are  complained  of.    Trophic  disturbances  are  sometimes  observed. 

Multiple  Neuritis,  Toxic. — Alcoholic  Neuritis. — This  is  exceedingly 
rare  in  children.  Only  a  few  cases  have  been  collected  from  the 
literature.    The  course  of  the  disease  is  similar  to  that  in  the  adult. 

Lead  Neuritis. — Neuritis  due  to  lead  poisoning  is  more  frequently 
observed  in  children  than  alcoholic  neuritis.  The  children  become 
exposed  to  lead  through  drinking  cups  and  toys.  The  course  of  the 
disease  differs  but  little  from  that  m  the  adult,  except  that  the  peroneal 
muscles  of  the  legs  are  first  attacked,  and  this  gives  rise  to  foot-drop. 
The  arms  are  later  involved,  the  distribution  being  that  of  the  radial 
nerve,  then  the  extensors  of  the  fingers  and  hand.  The  paralysis  is 
a  flaccid  one,  with  loss  of  reflexes,  a  positive  reaction  of  degeneration, 
and  muscular  atrophy.  There  are  no  sensory  disturbances.  Bladder 
and  rectal  disturbances  are  negative. 

As  m  the  adult,  lead  colic  is  frequently  complained  of.  xAnemia 
and  the  lead  line  are  often  present.  Encephalitis  with  convulsions, 
hemiplegia,  and  optic  neuritis  have  all  been  observed. 

The  prognosis  is  good  if  the  poison  can  be  completely  eliminated. 

Arsenical  Neuritis. — This  type  of  neuritis  has  occasionally  followed 
the  administration  of  Fowler's  solution  in  the  treatment  of  chorea  and 
other  maladies. 

It  is  characterized  by  symmetrical  atrophic  palsy  of  the  arms  and 
legs  which  develops  rapidly,  and  is  accompanied  by  neuralgic  pain 
and  hyperesthesia.  In  the  legs  the  peroneal  group  of  muscles  are 
especially  apt  to  be  involved;  whereas  in  the  arms  it  is  the  muscles 
supplied  by  the  radial  nerve.  The  nerves  and  muscles  are  pamful  on 
pressure.  There  are  muscular  atrophy,  an  absence  of  reflexes,  and  a 
reaction  of  degeneration.  Trophic  disturbances  of  the  skin — hyperi- 
drosis,  glossy  skin,  and  pigmentation — are  quite  characteristic. 

FACIAL   PARALYSIS. 

The  facial  nerve  may  be  aft'ected  anywhere  along  its  course,  either 
within,  the  cranium,  within  the  bony  canal,  or  after  its  exit  from  the 
cranium.  Obstetrical  facial  palsy,  which  results  from  injury  to  the 
nerve  at  birth,  either  by  pressure  of  the  forceps  or  some  obstacle  to 
the  passage  of  the  head  through  the  pelvis,  has  already  been  described 
(see  page  111). 

Other  etiological  factors  involving  the  portion  of  nerve  peripheral 
to  the  exit  from  the  cranium  are  cold  and  exposure  to  dampness  as 
seen  in  the  rheumatic  type,  the  pressure  of  enlarged  lymphatic  glands, 
mumps,  and  trauma,  such  as  a  severe  blow  on  the  ear,  or  following 
operations  on  glands  or  tumors  at  the  angle  of  the  jaw.  A  common 
cause  is  an  inflammation  of  the  nerve  within  the  Fallopian  canal 
produced  by  disease  of  the  middle  ear.    This  is  seen  most  frequently 


840  THE  NERVOUS  SYSTEM 

after  chi'onic  otitis  media,  especially  when  there  is  caries  of  the 
petrous  portion  of  the  temporal  bone,  due  very  commonly  to  tuber- 
culosis. 

Intracranial  diseases,  such  as  basilar  meningitis,  tumor,  or  a  fracture 
of  the  skull,  may  occasionally  give  rise  to  facial  palsy.  The  paralysis 
followmg  these  mtracranial  lesions  is  usually  complicated  by  other 
basal  palsies  and  cerebral  symptoms.  The  auditory  nerve  is  also 
likely  to  be  affected. 

Symptoms. — The  s}-mptoms  depend  upon  the  portion  of  the  nerve 
affected.  If  the  involvement  is  peripheral,  there  is  paralysis  of  all  the 
muscles  on  one  side  of  the  face,  including  those  of  the  forehead  and 
those  about  the  eye.  The  affected  side  fti  the  face  becomes  flaccid, 
in  consequence  of  which  the  mouth  is  usually  drawn  toward  the 
unaffected  side.  The  face  is  smooth;  the  nasolabial  fold  is  obliterated; 
the  child  is  miable  completely  to  close  the  eye  (lagophthalmus). 
Any  voluntary  movement  of  the  side  of  the  face  involved  is  impos- 
sible. 

There  is  inability  to  wrinkle  the  forehead,  to  pucker  the  lips,  to 
contract  the  eyebrows,  to  whistle,  or  to  puff  out  the  affected  cheek. 
Nursing  and  mastication  are  mterfered  with.  If  the  paralysis  is 
complete  there  is  difficulty  m  deglutition  and  articulation.  Inequality 
of  the  face  is  evident  when  the  muscles  are  brought  into  action,  as  in 
laughmg  or  crying.  Sensory  distiu-bances  do  not  appear.  The  elec- 
trical reactions  depend  upon  the  extent  of  mjury,  varying  from 
dimmished  electrical  irritability  to  a  reaction  of  degeneration. 

If  the  invoh'ement  be  withm  the  bony  canal,  and  is  the  result  of  a 
previous  middle-ear  disease,  there  is  usually  a  history  of  discharge 
from  the  ear  and  some  deafness.  The  symptoms  are  the  same  as 
those  mentioned  above  from  peripheral  involvement.  As  the  chorda 
tjTiipani  is  given  off  within  the  canal  there  is,  in  addition,  a  dis- 
turbance of  the  sense  of  taste  in  the  anterior  third  of  the  tongue, 
together  with  a  dimmution  of  the  salivary  secretion.  If  the  involve- 
ment be  intracranial,  due  either  to  a  basilar  meningitis,  a  tumor,  or 
a  fracture,  the  auditory  nerve  is  usually  similarly  involved,  and  in 
addition  there  are  cerebral  symptoms.  If  the  lesion  is  central  and 
above  the  nuclei  of  the  seventh  cranial  nerve,  the  superior  branch 
innervating  the  muscles  of  the  forehead  usually  escapes,  the  elec- 
trical reactions  are  normal,  and  there  are  generally  paralyses  of  the 
extremities. 

Prognosis. — In  the  rheimiatic  form,  as  a  rule,  recovery  takes  place 
in  several  weeks  or  months.  In  palsies  due  to  middle-ear  disease  the 
outlook  is  less  favorable,  and  permanent  paralysis  is  likely  to  result 
in  muscular  contractions  which  give  rise  to  spasms  and  twitchings. 
With  respect  to  palsies  which  are  caused  by  mtracranial  involvement, 
the  result  depends  upon  the  etiological  factor. 

Diagnosis. — In  the  majority  of  cases,  the  diagnosis  of  facial  paralysis 
offers  no  difficulty.  To  get  a  clear  conception  of  the  case,  its  cause, 
the  location  of  the  lesion,  and  the  extent  of  the  involvement  must  be 


CHOREA  841 

determined.     It  is  also  highly  important  to  differentiate  between  a 
peripheral  lesion  and  a  central  one  above  the  pons. 

Treatment. — ^The  treatment  depends  upon  the  causative  factor. 
In  the  rheumatic  form,  hot  applications,  local  bleeding  from  behind 
the  ear,  and  blistering  are  extremely  beneficial,  in  conjunction  with 
the  administration  of  the  salicylates.  When  due  to  ear  disease,  appro- 
priate local  treatment  should  be  begun,  and  massage  and  electricity 
resorted  to  in  all  stubborn  cases. 

CHOREA. 

Synonyms. — St.  Vitus'  Dance — St.  Anthony's  Dance — Sydenham's 
Chorea — Chorea  Minor. 

Definition. — Chorea  is  an  affection  of  the  nervous  system,  charac- 
terized by  incoordination  and  paresis  of  the  muscles  of  the  body, 
and  by  a  tendency  to  cardiac  complications.  Involuntary  muscular 
movements,  twitchings,  and  emotional  instability  are  among  the 
prominent  features  of  the  disease.  It  is  now  regarded  as  infectious, 
and  may  occur  sporadically  or  in  epidemics. 

Many  varieties  of  chorea  have  been  described,  grouped  according 
to  the  prominence  of  one  or  more  special  symptoms.  Among  these 
may  be  mentioned  chronic  progressive  chorea,  chronic  adult  chorea, 
chorea  major,  congenital  and  senile  chorea,  posthemiplegic  chorea, 
chorea  gravidarum,  and  choreic  insanity.  Dubini's  disease,  or  elec- 
tric chorea,  is  a  form  marked  by  sudden  spasms. 

Etiology. — The  specific  organism  which  produces  chorea  is  unknown; 
but  because  of  the  frequent  association  of  this  disease  with  rheumatism, 
and  the  tendency  to  cardiac  complications  which  it  exhibits,  it  is 
believed  to  be  closely  allied  to  the  microorganism  which  causes  rheu- 
matism. This  close  association  of  the  two  diseases  is  showai  m  the 
following  summary,  given  by  Fischer,  of  cases  that  have  been  reported. 

Of  Steiner's  252  cases,  4  suffered-  from  rheumatism;  of  Sachs'  70 
cases,  6;  of  Sinkler's  279  cases,  37;  of  Crandall  and  Holt's  146  cases, 
63;  and  of  Fischer's  100  cases,  25. 

There  is  also  in  these  cases  a  marked  tendency  to  tonsillitis,  and  in 
a  large  majority  of  instances  of  chorea  we  find  hj-pertrophied  and 
diseased  tonsils,  all  of  which  serves  to  link  rheumatism  and  chorea 
closer  together,  and  to  lead  to  the  suspicion,  or  belief,  that  the 
infecting  organisms  which  produce  these  diseases  gain  entrance  to  the 
system  via  the  tonsils. 

Fright  and  nervous  shock  have  been  thought  to  play  an  important 
part  in  the  etiology  of  chorea;  but  it  seems  more  probable  that  these 
should  be  regarded  as  immediately  exciting  causes  rather  than  predis- 
posing factors.  In  epidemics,  especially  those  occurring  in  institutions, 
imitation  may  be  responsible  for  a  certain  number  of  cases,  but  only 
as  an  exciting  factor. 

Among  other  causes  leading  to  chorea  may  be  mentioned  overwork 
at  school,  reflex  irritation  from  pruritus,  adenoids,  poh'pi,  phimosis. 


842  THE  NERVOUS  SYSTEM 

eye  strain,  intestinal  parasites,  and  menstrual  disorders.  Heredity 
is  another  important  predisposing  factor,  and  in  many  cases  the  child's 
neurotic  tendencies  can  be  traced  to  neuropathic  parents,  or  we  find 
a  family  history  of  gout,  rheumatism,  tuberculosis,  or  other  constitu- 
tional dyscrasia.  Chronic  malaria,  anemia,  and  chronic  gastro-mtes- 
tinal  disturbances  are  common  findings.  ^Masturbation  is  practised 
by  many  of  these  children,  and  the  habit  is  frequently  a  forerunner 
of  the  disease. 

One  of  the  most  marked  characteristics  in  the  etiology  of  chorea 
is  sex,  for  ghls  are  affected  twice  or  even  three  times  as  often  as  boys. 
In  a  series  of  cases  reported  by  Smkler,  232  of  328  were  m  females. 
Chorea  is  especially  common  from  the  seventh  to  the  fifteenth  year,  is 
rare  before  the  third  year,  is  practically  never  seen  m  infants,  and  in 
adults,  as  a  rule,  is  observed  only  in  pregnant  women. 

In  the  eastern  part  of  the  United  States  the  majority  of  cases 
occur  in  the  spring  months,  and  fewest  in  the  early  winter,  the  seasonal 
curve  corresponding  to  that  of  rheumatism.  Chorea  is  most  common 
among  Russian  Jews,  and  rare  among  negroes. 

Pathology. — The  pathology  of  chorea  has  not  been  determined, 
and  there  is  at  present  great  diversity  of  opinion  on  this  subject. 
It  is  obvious  that  there  can  be  no  extensive  or  permanent  lesions  m 
the  nervous  system,  because  complete  recovery  usually  ensues  a  few 
weeks  after  the  onset  of  the  affection.  The  process  is  probably  toxic 
m  nature,  and  affects  the  central  nervous  system,  especially  the  motor 
cortex  about  the  Rolandic  area. 

It  is  reasonable  to  assume  that  in  those  cases  associated  with  rheu- 
matism, and  in  which  there  is  cardiac  mvolvement,  the  same  toxin 
which  affects  the  nervous  system  also  damages  the  heart.  In  fatal 
cases,  the  diplococcus  of  Poynton  and  Paine  has  been  isolated  from 
the  pia  mater,  and  in  those  fatal  cases  associated  with  endocarditis, 
capillary  emboli  were  found  in  the  brain.  Few  cases,  however,  show 
any  pathological  lesions,  and  no  constant  or  permanent  changes  have 
been  found  in  the  cases  which  have  been  studied  postmortem. 

Symptoms. — The  mamier  of  onset  m  chorea  is  very  variable,  and 
an  attack  may  be  preceded  by  a  prodromal  period  of  several  days  or 
even  a  week.  As  a  rule  the  disease  comes  on  gradually,  the  child 
being  at  first  a  little  more  "nervous,"  irritable,  and  fretful  than 
usual,  and  crymg  on  the  slightest  provocation.  Restlessness  at  night 
and  slight  twitchings  during  the  day  may  be  observed,  also  awkward- 
ness and  clumsmess,  especially  in  handling  objects.  Spoons,  pencils, 
and  books  are  unaccomitably  dropped,  and  the  child  is  scolded  for 
carelessness.  It  becomes  increasingly  difficult,  and  later  impossible, 
for  the  patient  to  use  its  tumbler,  knife  and  fork,  pencil  and  pen,  or 
to  dress,  most  of  all  to  execute  fine  movements,  such  as  buttoning  the 
clothes.  Other  delicate  movements,  such  as  threading  needles  or 
sewmg,  are  also  impossible,  and  the  child  frequently  trips  and 
stumbles. 

Following  these  sjinptoms  the  unmistakable  signs  of  the  disease 


CHOREA  843 

are  usually  recognized,  the  boy  or  girl  exhibiting  awkward  involun- 
tary and  irregular  muscular  movements,  which  are  intensified  by  any 
effort  on  the  part  of  the  child  to  control  them.  These  incoordinate 
jerking  muscular  contractions,  which  may  involve  all  or  any  part 
of  the  body,  constantly  take  place  while  the  patient  is  awake,  but 
involve  alternately  various  groups  of  muscles,  and  cease  only  when 
the  child  is  sound  asleep.  The  muscles  of  the  hands,  arms,  legs,  and 
face  are  the  ones  most  commonly  affected,  and  the  tongue  may 
become  involved  to  such  an  extent  as  to  interfere  with  speech. 

These  movements  are  never  rhythmical  or  symmetrical,  and  one 
extremity  may  be  affected  to  a  greater  extent  than  its  fellow.  The 
usual  order  of  involvement  is  first  the  right  arm,  left  arm,  right  leg, 
and  left  leg.  When  the  shoulders  are  affected  they  jerk  up  and  down, 
the  arms  rotate  from  side  to  side  or  swing  backward  and  forward, 
the  hands  are  flexed,  extended,  pronated,  and  supinated  in  turn, 
while  the  fingers  are  rigidly  contracted  and  bent,  rendering  the  child 
unable  to  hold  anything. 

The  lower  extremities  may  be  involved  to  such  an  extent  that  the 
child  can  neither  sit,  stand,  nor  lie  still,  and  in  severe  cases  it  must 
be  restrained  to  prevent  it  from  mjuring  itself.  The  face  may  assume 
a  number  of  expressions,  and  is  constantly  distorted.  A  systolic  heart 
murmur  is  frequently  heard,  and  at  the  height  of  an  attack  the  pulse 
may  be  arrhythmical,  and  the  respirations  irregular. 

As  a  rule  the  choreiform  movements  extend  to  all  parts  of  the 
body,  but  in  25  to  33  per  cent,  of  the  cases  they  are  limited  to  one 
side  of  the  body,  the  other  manifestations  of  the  disease  being  just 
the  same  as  when  all  of  the  muscles  are  involved.  Hemichorea  is, 
however,  usually  regarded  as  more  serious,  because  it  is  often  asso- 
ciated with  paresis  of  the  affected  extremities,  also  with  psychical 
complications,  such  as  melancholia  and  hallucinations. 

In  all  cases  of  chorea  there  is  weakness  of  the  muscles,  yet  exhaus- 
tion is  rare,  and  the  child  does  not  complain  of  being  tired.  This 
paretic  state  of  the  muscles  can  readily  be  demonstrated  by  asking 
the  patient  to  grasp  the  examiner's  hand.  To  test  for  incoordination 
the  child  should  be  told  to  extend  the  arms  outward,  and  then  to  touch 
the  tip  of  the  nose  with  each  index  finger  alternately,  or  to  bring  the 
tips  of  the  index  fingers  together  quickly  after  the  arms  have  been 
extended  outward. 

The  facial  muscles  may  be  so  affected  that  the  brow  cannot  be 
wrinkled,  the  eyes  kept  shut,  or  the  tongue  held  out  for  more  than  a 
few  seconds.  In  severe  cases  the  child  is  unable  to  walk,  talk,  chew, 
or  control  the  bowels  and  bladder;  it  appears  to  be  paralyzed,  and 
presents  a  pitiful  spectacle. 

There  is,  as  a  rule,  well-marked  secondary  anemia  in  chorea.  The 
urine  usually  contains  an  excess  of  uric  acid.  Herter  has  demon- 
strated the  presence  of  hematoporphyrin  in  the  urine — in  both  chorea 
and  rheumatism.  Heart  murmurs  are  frequently  heard;  and,  while 
some  of  them  may  be  of  anemic  origin,  the  majority  are,  unfortu- 


844  THE  NERVOUS  SYSTEM 

nately,  due  to  intercurrent  endocarditis,  being  diastolic  or  apical- 
systolic  in  time.  Pericarditis  may  also  appear  as  a  complication  of 
chorea. 

There  is  marked  disturbance  of  nutrition,  and  the  appetite  is  usually 
impaired.  Pain  is  not  uncommon,  and  in  many  cases  is  of  rheu- 
matic origin.  The  mental  state  of  these  patients  varies.  At  the 
onset  there  is  hyperexcitability  and  irritability,  later  the  children 
become  emotional,  laughing  or  crying  upon  slight  cause.  In  very 
severe  cases,  melancholic  or  maniacal  symptoms  may  develop.  Unless 
complicated  by  rheumatism  or  endocarditis,  there  is  no  elevation  of 
temperature  in  chorea. 

Diagnosis. — The  diagnosis  is  readily  made,  and  is  based  upon  the 
characteristic,  sudden,  irregular,  involuntary,  and  spasmodic  move- 
ments of  the  body  and  on  the  abnormal  movements  of  the  tongue. 
Habit  spasm  may  sometimes  simulate  chorea;  but  in  habit  spasm 
the  movements  are  to  some  extent  under  the  control  of  the  will,  while 
any  attempt  to  control  choreiform  movements  will  only  exaggerate 
them.  Hemiplegia  may  be  simulated  by  the  pseudoparalysis  in  chorea; 
but  chorea  may  be  ruled  out  by  the  absence  of  spasticity  and  increased 
reflexes. 

Choreic  movements  are  sometimes  associated  with  infantile  cerebral 
palsies ;  but  true  chorea  can  here  be  excluded  because  of  the  increased 
reflexes  and  spasticity  which  accompany  infantile  cerebral  palsies. 
Imitative  choreiform  movements  are  of  short  duration,  and  in  hyster- 
ical chorea  the  movements  are  to  a  certain  extent  purposeful,  not  so 
irregular  as  in  true  chorea,  and  other  symptoms  of  hysteria  are 
demonstrable. 

Course  and  Duration. — Chorea  is  a  self-limited  disease,  and,  if 
untreated,  usually  ends  in  recovery  in  from  six  to  ten  weeks.  The 
active  symptoms  yield  in  about  four  weeks;  but  the  condition  of  the 
child's  nervous  system  influences  both  the  course  and  duration,  and 
in  a  few  cases  chorea  may  last  for  six  months,  or  become  chronic  and 
persist  indefinitely.  In  other  cases  only  certain  local  spasms  may 
continue  for  a  long  or  short  time.  The  intensity  of  the  attack  has 
apparently  no  effect  on  its  duration,  and  many  severe  cases  under 
careful  treatment  recover  within  the  usual  time. 

Prognosis. — In  the  cases  without  cardiac  involvement,  the  prognosis 
is  uniformly  good,  and  complete  recovery  the  rule;  but  relapses  are 
quite  common,  and  render  the  prospect  of  permanent  recovery  rather 
unfavorable.  Relapses  are  most  common  in  the  spring  following  the 
first  attack,  and  some  children  have  an  attack  every  year  for  three 
or  four  years  in  succession.  The  outlook  is  serious  in  all  cases  asso- 
ciated with  delirium  and  prostration,  as  well  as  in  those  cases  compli- 
cated by  cardiac  lesions. 

Treatment. — Since  chorea  is  known  to  occur  in  epidemics,  it  is  wise 
to  isolate  the  child  affected  from  other  children,  and  especially  is  this 
advisable  in  boarding  schools,  asylums,  hospitals,  and  other  institu- 
tions where  the  inmates  are  closely  thrown  together.    This  measure 


CHOREA  845 

is  particularly  important  in  the  case  of  girls  between  the  ages  of  seven 
and  fifteen,  when  they  are  most  susceptible  to  the  affection. 

The  management  of  a  case  of  chorea  depends  to  some  extent  upon 
the  severity  of  the  attack;  but  in  any  case  the  general  care  of  the 
patient  is  of  quite  as  much,  if  not  of  more,  importance  than  the 
admuiistration  of  drugs.  Rest  in  bed  for  two  to  four  weeks  is  neces- 
sary in  severe  cases,  and  restraint  may  be  required  to  keep  the  patient 
from  falling  on  the  floor. 

The  child's  room  should  be  sunny  and  airy.  All  excitement  should 
be  avoided,  and  no  visitors  should  be  permitted  in  the  room;  but  the 
patient  may  be  allowed  to  play  with  a  few  toys,  and  the  attendant 
should  endeavor  to  amuse  and  entertain  it  in  a  quiet  way.  After  the 
coarser  movements  have  ceased,  the  child  may  be  allowed  to  sit  up 
and  go  about  the  room  for  a  little  while  each  day,  gradually  increasing 
the  time  spent  out  of  bed  as  improvement  sets  in. 

If  there  is  any  evidence  of  cardiac  involvement,  rest  in  bed  should 
be  enforced  for  a  longer  period,  and  the  patient  should  not  be  allowed 
to  sit  up  until  the  physician  feels  assured  that  the  lesion  is  a  per- 
manent one.  After  the  child  is  out  of  bed,  a  reasonable  amount  of 
outdoor  life  should  be  advised,  but  the  mother  or  nurse  must  be  care- 
ful not  to  let  the  patient  become  fatigued,  either  physically  or  men- 
tally. It  is  a  good  plan  to  have  these  children  take  one  or  two  naps 
during  the  day. 

Even  in  very  light  cases  the  child  should  be  taken  out  of  school, 
and  it  should  never  be  subjected  to  ridicule  or  any  punishment.  Play- 
ing with  other  children  should  be  prohibited  until  some  time  after 
convalescence.  Exciting  books,  games,  and  pictures  should  be  for- 
bidden, and  an  effort  made  to  surround  these  children  wdth  a  quiet 
but  interesting  environment.  Sometimes  it  is  necessary  to  take  the 
child  aw^ay  from  home  for  awhile,  particularly  an  older  child. 

In  severe  cases,  hospital  treatment  and  care  are  usually  more  bene- 
ficial and  satisfactory  than  home  management.  Cold  douches  or 
warm  baths  and  massage  daily  are  of  advantage  in  chorea,  and  some 
authorities  recommend  a  daily  colonic  flushing. 

The  diet  should  be  a  bland  one,  the  food  depending  upon  the  age 
and  digestive  capacity  of  the  child.  Milk  is  one  of  the  best  articles 
of  diet  for  these  children,  and  cereals,  weak  broths,  chicken,  cooked 
fruits,  and  fresh  vegetables  may  be  given.  Tea  and  coftee,  rich  soups, 
sweets,  pastries,  and  other  indigestible  foods  should  be  prohibited. 

The  two  best  drugg  in  chorea  are  iron  and  arsenic;  but  in  the  rheu- 
matic cases  the  salicylate  of  soda,  in  10-grain  doses,  combined  with  an 
equal  dose  of  bicarbonate  of  soda,  three  tmes  daily,  is  most 
effectual. 

Arsenic  is  given  three  times  a  day  in  the  form  of  Fowler's  solution, 
beginning  with  2  or  3  drops  in  plenty  of  water  after  meals,  and 
increasing  the  daily  dose  by  1  drop  until  9  to  15  drops  are  taken  three 
times  a  day,  unless  gastro-intestinal  disturbances,  puffiness  under 
the  eyes,  and  headache  appear,  when  the  "arsenic  should  be  imme- 


846  THE  NERVOUS  SYSTEM 

diately  stopped  for  a  few  days,  then  resumed  in  small  doses  as  before. 
It  is  never  wise  to  give  more  than  15  drops  three  times  a  day,  and  this 
maximum  dosage  should  be  kept  up  for  only  a  few  days,  and  then 
gradually  diminished  to  5  drops  three  tim.es  a  day. 

In  many  cases  arsenic  lessens  the  severity  of  the  symptoms  and 
shortens  the  attack;  but,  if  there  are  no  appreciable  results  after  two 
or  three  weeks  of  its  administration,  it  might  as  well  be  discontinued. 
The  urine  should  frequently  be  examined  while  Fowler's  solution  is 
being  given,  and,  should  albumin  appear,  the  arsenic  should  be 
immediately  stopped. 

Iron  may  be  given  in  the  form  of  the  citrate,  |  to  1  grain,  or  in  one 
of  the  various  preparations,  such  as  the  peptomangan  (Gude's),  1  dram, 
or  I  grain  of  ferri  sulphatis,  three  times  a  day  after  meals.  Chloral, 
grains  1  to  3,  or  veronal  or  trional,  grains  3  to  5,  may  be  given  once 
or  twice  daily  to  older  children  for  their  sedative  effect. 

In  severe  cases  morphine  sulphate,  ^  to  ^-^  of  a  grain,  hyoscine 
hydrobromate,  ^io"  to  t|-o  of  a  grain,  or  chloral  hydrate,  5  to  10  grains, 
may  be  necessary  to  quiet  the  patient.  Antipyrine,  15  to  20  grains 
daily,  and  strychnine  sulphate,  gV  of  a  grain  three  times  a  day,  are 
useful  in  some  cases.  Some  children  respond  well  to  the  sedative  effect 
of  sodium^  bromide,  3  to  5  grains  every  three  hours.  The  bowels  should 
be  regulated  by  dram  doses  of  magnesium  sulphate,  or  ^-  to  1-dram 
doses  of  aromatic  fluid  extract  of  cascara  sagrada. 

In  cases  of  rheumatic  origin  it  is  wise  to  confine  the  treatment  to 
antirheumatic  lines,  giving  sodium  salicylate  or  aspirin  in  5-grain 
doses  four  times  a  day,  and  restricting  the  diet  accordingly. 

The  treatment  which  a  <ihild  receives  during  convalescence  from 
chorea  is  of  the  utmost  importance  because  of  the  marked  tendency 
to  relapse,  especially  during  the  spring  months.  Work  in  school 
should  not  be  resumed  for  several  months  after  recovery,  and  these 
children  should  be  sent  to  the  country  or  seashore  to  recruit. 

The  diet  should  be  very  nutritious,  the  warm  or  cold  baths  should 
be  continued,  and  mild  exercise  indulged  in.  The  anemia  should  be 
combated  by  the  use  of  cod-liver  oil,  ^  to  1  dram,  or  the  syrup  of 
ferrous  iodide,  5  to  20  drops,  three  times  a  day  after  meals. 

Any  source  of  reflex  irritation,  such  as  eye  strain,  hypertrophied 
tonsils  and  adenoids,  or  phimosis,  should  be  removed.  For  children 
who  are  subject  to  recurrent  attacks  of  chorea,  courses  of  the  salicyl- 
ates or  of  Fowler's  solution  are  advisable  during  the  periods  of  appa- 
rently complete  recovery.  Rheumatic  cases  subject  to  relapses  some- 
times remain  free  from  attacks  indefinitely  if  removed  from  a  damp, 
cold  climate  to  a  warm,  dry  one. 

TETANY. 

Tetany  is  a  motor  neurosis,  marked  by  persistent  or  intermittent, 
and  more  or  less  painful,  spasms  of  the  muscles  of  the  upper  and  lower 
extremities.    It  is  a  condition  rather  than  a  disease,  and  is  believed 


TETANY  847 

to  be  a  symptom  of  several  different  affections.  Most  cases  occur 
in  the  spring. 

Forms  of  the  Disease. — Tetany  may  occur  in  either  adults  or  chil- 
dren, and  in  Australia  it  has  been  observed  in  epidemics.  There  is 
also  a  surgical  form.  In  attempting  to  classify  the  m.alady  according 
to  symptoms,  we  find  one  group  of  cases  in  which  the  muscular  con- 
tractions are  persistent,  and  another  in  which  they  are  intermittent. 

Etiology. — The  affection  is  not  so  common  in  America  as  it  is  in 
Austria  and  Sweden,  and  some  other  parts  of  the  world;  but  it  is 
probably  more  frequently  met  with  in  this  country  than  is  generally 
supposed.  The  majority  of  cases  occur  in  infants  between  the  third 
month  and  the  second  year.  It  is  less  common  during  later  childhood, 
and  is  rarely  seen  in  adults.  Children  of  the  poorer  classes,  whose 
surroundings  are  unhygienic  and  unhealthful,  furnish  most  of  the 
cases,  and  in  more  than  50  per  cent,  of  all  instances  of  tetany  there 
is  an  associated  rachitis  which  is  believed  to  be  an  important  etio- 
logical factor. 

Beyond  this  the  etiology  of  tetany  is  very  obscure.  It  is  usually 
preceded  by  some  depressing  or  debilitating  condition,  and  never 
affects  healthy  children.  Among  the  different  etiologic  factors  which 
have  been  mentioned  are  gastro-intestinal  disturbances,  infection 
and  infestation  of  the  intestines  by  parasites,  the  transmissible  dis- 
eases, poisoning  by  alcohol,  lead,  and  ergot,  extirpation  of  the  para- 
thyroid glands,  or  deficient  parathyroid  metabolism.  In  some  cases 
tetany  is  supposed  to  be  a  manifestation  of  hysteria. 

Many  observers  believe  tetany  to  be  due  to  a  deficiency  of  calcium 
salts  or  a  disturbance  of  calcium  metabolism,  and  artificial  tetany 
has  been  relieved  by  the  injection  of  calcium.  In  cases  of  the  disease 
there  is  a  diminution  of  calcium  salts  in  the  brain,  an  increase  of  cal- 
cium phosphate  and  ammonia  in  the  urine,  and  an  increase  of  ammonia 
in  the  blood.    Tetany  is  also  believed  to  be  of  toxic  origin. 

Pathology, — Few  pathological  changes  and  no  characteristic  lesions 
have  been  observed  in  the  small  number  of  cases  of  tetany  which 
have  come  to  autopsy.  Dercum  mentions  as  the  conditions  to  be 
found  postmortem  proliferation  of  the  neuroglia,  atrophy  m  the  gan- 
glion cells  and  nerve  fibers,  serous  exudation  into  the  cervical  cord  and 
ventricles  of  the  brain,  spinal  extradural  hemorrhage,  and  sclerotic 
changes  in  the  nervous  system.  Other  observers  have  reported 
periarteritis,  phlebitis,  bronchopneumonia,  chronic  gastro-enteritis, 
tuberculosis  of  the  brain,  and  hemorrhages  into  the  parathyroid  glands. 

Symptoms. — The  most  important  symptoms  of  tetany  are  the  result 
of  mechanical  or  reflex  excitability  of  the  spinal  cord  and  peripheral 
nerves,  and  they  may  appear  suddenly  or  gradually.  In  some  cases 
there  is  a  prodromal  period,  during  which  the  child  may  be  depressed, 
dull,  stupid,  it  may  complain  of  headache  or  dizziness,  and  of  pain  in 
the  extremities.  This  is  quickly  followed  by  a  tonic  spasm  of  the 
muscles,  most  marked  in  the  arms,  which  are  held  close  to  the  chest, 
and  flexed  at  the  elbow,  wrist,  and  finger-joints.    The  rigidity  is  some- 


848 


THE  NERVOUS  SYSTEM 


times  so  pronounced  that  it  is  impossible  to  overcome  the  resistance 
of  the  contracted  muscles. 

The  muscles  of  the  leg  are  less  commonly  affected,  and  those  of 
the  face,  neck,  and  trunk  are  rarely  involved.  The  hand  assumes 
a  characteristic  position,  known  as  the  "accoucheur's"  or  "writer's 
hand,"  the  fingers  being  flexed  on  the  metacarpophalangeal  joints, 
while  the  phalanges  are  extended,  the  thumbs  adducted,  and  the  wrist 
is  acutely  flexed  with  the  hand  turned  to  the  ulnar  side.  The  hands 
may  also  take  the  position  seen  in  driving. 

The  foot  may  be  extended  or  hyperextended,  and  the  toes  flexed. 
Often  the  feet  take  the  position  seen  in  talipes  equinus.  In  rare 
cases,  all  of  the  muscles  of  the  body  may  be  involved  (Fig.  119). 


Fig.  89.— Tetany. 


During  the  periods  of  latency  the  contractures  lessen,  and  may 
disappear  to  such  an  extent  that  the  only  noticeable  symptom  is 
hyperexcitability  of  the  muscles  and  nerves.  The  affection  may 
last  but  a  few  hours  or  for  several  weeks,  or  the  child  may  have  a  suc- 
cession of  periodic  attacks.  During  the  latent  periods  in  which  there 
are  no  active  symptoms,  certain  phenomena  may  be  elicited  which 
will  enable  the  practitioner  to  determine  that  he  is  dealing  with 
tetany. 

Trousseau's  sign  is  a  spasm  of  the  muscles  of  the  forearm  and 
fingers  produced  when  the  arm  is  compressed  by  an  elastic  band. 
Chvostek's  sign  is  manifested  by  a  contraction  of  the  muscles  of  the 
face  or  forehead  when  they  are  tapped;  sometimes,  as  a  result  of  the 
tapping,  other  muscles  of  the  body  also  contract.  Erb's  sign  is  evoked 
by  increased  electrical  excitability  of  the  peripheral  nerves,  muscular 


TETANY  849 

contractions  being  produced  by  very  weak  currents.  Schultz's  sign 
is  elicited  by  stroking  the  skin  over  the  zygoma,  whereupon  contrac- 
tures appear,  similar  to  those  which  constitute  Chvostek's  sign,  but 
Schultz's  phenomenon  is  observed  only  in  the  most  severe  cases, 
therefore  is  seldom  demonstrated. 

Pain  is  usually  present  during  the  spasm,  and  may  be  so  severe 
as  to  make  the  child  cry  out.  Any  attempt  to  overcome  the  spasm 
greatly  increases  the  pain,  and  pressure  on  the  contracted  part  is 
also  painful. 

Among  the  other  symptoms  of  sensor}'  disturbance  are  tinnitus 
aurium  and  vertigo.  There  is  no  loss  of  consciousness  unless  convul- 
sions occur;  the  urine  is  rarely  affected;  the  pulse  is  but  slightly 
accelerated;  there  is  no  elevation  of  temperature  unless  it  is  caused 
by  some  associated  or  underlying  condition,  or  by  the  toxemia  usually 
present.    Laryngospasm  is  a  common  occurrence. 

Diagnosis. — ^This  offers  no  difficulty,  being  based  upon  the  bilateral 
contractions  of  the  hands  and  feet  which  are  so  characteristic  of  the 
disease,  also  upon,  evidences  of  increased  excitability  of  the  peripheral 
nerves,  as  expressed  by  the  various  signs  above  mentioned.  A  history 
of  preceding  gastro-intestinal  disease,  the  existence  of  rickets,  and  the 
fact  that  there  is  no  loss  of  consciousness,  are  all  important  points 
which  must  be  taken  into  consideration. 

Tetanus  may  be  excluded  by  the  location  of  the  contractures,  the 
absence  of  trismus,  and  the  intermittency  of  the  spasms.  Meningitis 
may  be  ruled  out  by  the  lack  of  mental  symptoms,  while  lesions  of 
the  brain  may  be  dismissed  from  consideration  by  the  fact  that  there 
are  no  local  symptoms,  and  that  the  contractm'es  in  tetany  are  bilat- 
eral and  symmetrical.  Trousseau's  sign  is  demonstrable  even  during 
the  latent  periods,  and  enables  one  to  diagnose  the  affection  when 
spasms  do  not  occur. 

Prognosis. — ^Tetany  is  not  a  fatal  disease  unless  associated  with 
general  convulsions,  although  death  may  ensue  as  a  result  of  the 
underlying  condition;  therefore  the  prognosis  depends,  to  a  great 
extent,  upon  the  cause  of  the  affection  in  each  individual  case.  As 
a  rule,  cases  of  tetany  due  to  malnutrition  or  intestinal  toxemia  tend 
to  recover  under  proper  treatment,  while  tetany  caused  by  organic 
lesions  in  other  organs  or  due  to  eclampsia  is  miore  serious,  and  the 
outlook  not  so  favorable. 

Treatment. — The  treatment  of  tetany  should  be  directed  chiefly 
to  the  underlying  cause  which  must  be  eliminated  as  quickly  as 
possible.  Rickets,  if  present,  should  be  promptly  treated  by  regula- 
tion of  the  diet  and  the  administration  of  remedies  suggested  in  the 
discussion  of  the  treatment  of  that  disease.  Furthermore,  since  intes- 
tinal toxemia  and  malnutrition  are  important  factors  in  the  produc- 
tion of  tetany  in  children,  any  disturbances  of  the  gastro-intestinal 
cract  should  be  corrected,  and  the  diet  and  nutrition  regulated. 

An  initial  purge  of  castor  oil,  1  to  3  drams,  should  be  given,  and 
at  intervals  of  five  days  or  a  week  these  children  should  take  1  or  2 
54 


850  THE  NERVOUS  SYSTEM 

grains  of  calomel  in  divided  doses.  An  enema  of  salt  solution  or  soap- 
suds is  often  productive  of  good  in  acute  cases. 

These  infants  should  be  kept  upon  breast  milk  whenever  practic- 
able, and  artificially  fed  infants  should  be  given  a  milk  mixture  care- 
fully modified  to  meet  the  dietetic  conditions. 

In  addition  to  this  regulation  of  the  diet,  the  physician  should  see 
that  the  child's  surroundings  are  as  hygienic  as  possible,  and  that  it 
gets  plenty  of  fresh  air  and  sunshine.  During  an  attack  various 
measures  may  be  employed  to  relieve  the  spasm.  The  child  must  be 
kept  quiet  and  warm,  and  all  disturbing  noises  should  be  prevented. 
A  hot  bath  at  110°  F.  may  be  given  twice  or  three  times  daily  for  its 
relaxing  effect  during  the  attack.  In  th.e  interval  between  attacks, 
a  salt  bath  should  be  given  each  evening,  followed  by  an  inunction 
of  olive  oil. 

The  most  valuable  sedatives  are  calcium  bromide,  sodium  bromide, 
and  chloral  hydrate.  Calcium  bromide,  which  may  be  given  in  5- 
to  10-grain  doses  every  four  hours,  not  only  counteracts  the  hyper- 
excitability,  but  also  supplies  to  the  system  the  calcium  which  it 
requires.  Sodium  bromide  may  be  given  orally  in  1-  to  3-grain  doses 
every  two  hours,  or  may  be  combined  in  5-  to  10-grain  doses  with 
chloral  hydrate,  grains  1  to  3,  and  be  given  by  rectum. 

In  these  cases  parath^Toid  extract  usually  has  no  perceptible  effect, 
and  the  administration  of  calcium  lactate,  2  to  5  grams  at  a  dose, 
is  followed  by  no  change  whatsoever  in  the  condition. 

During  convalescence,  cod-liver  oil,  20  to  60  drops,  and  iron  and 
ammonia  citrate,  |  to  1  grain,  or  syrupi  ferri  iodidi,  5  to  10  drops, 
may  be  given  after  meals.  Outdoor  life  in  the  country  is  a  valuable 
aid  in  promoting  speedy  recovery. 


CHAPTER  XXVI. 
PUBERTY. 

Because  puberty  lies  just  on  the  boundary  line  between  childhood 
and  adolescence,  this  subject  is  treated  fully  neither  in  classical  text- 
books on  pedriatics  nor  in  treatises  on  general  medicine.  This  lack  of 
comprehensive  study  probably  accounts  for  the  fact  that,  with  many 
physicians,  vague  notions  transmitted  by  hear-say  or  empiric  writings 
take  the  place  of  exact  knowledge  of  the  physiological  and  pathological 
changes  which  occur  at  this  critical  period. 

What  is  puberty?  The  name,  derived  from  pubes  or  pubis  (hair), 
would  apply  physiologically  to  the  time  of  the  appearance  of  hair  on 
the  genitals  (pubes).  This  coincides  approximately  with  the  estab- 
lishment of  the  procreative  faculty,  which  is  characterized,  according 
to  sex,  by  ovulation  or  the  maturing  of  spermatozoa,  and  usually, 
but  not  necessarily,  with  the  growth  of  pubic  hair.  Here,  however, 
local  conditions  only  are  considered,  while  the  profound  changes  which 
actually  occur  involve  the  whole  organism,  body  as  well  as  mind. 

In  trying  to  time  this  evolution  we  speak,  as  always  when  growth 
and  development  are  concerned,  only  of  the  average.  It  is  a  well- 
known  fact  that  some  girls  begin  to  menstruate  at  the  age  of  eleven, 
ten,  or  even  less,  and  others  not  before  their  fifteenth  or  sixteenth 
year,  while  conception  has  been  reported  as  early  as  the  eighth  year. 
In  boys,  too,  manifestations  of  puberty  are  sometimes  observed  at 
twelve  years  of  age,  in  others  not  before,  or  even  later  than,  eighteen 
years.  Equally  true  is  it  that  while  in  some  children  the  processes 
of  evolution  are  complete  in  eighteen  months,  or  even  a  year,  in  others 
eight  to  ten  years  may  elapse  before  m-atiu-ity  is  attained. 

Summarizing,  we  designate  as  puberty  the  whole  period  of  develop- 
ment between  twelve  and  fifteen  years  in  girls  and  fourteen  to  eighteen 
years  in  boys,  and  this  development  comprises  the  series  of  changes, 
physical  and  psychical,  which  transform  the  juvenile  organism  into 
the  mature  one.  These  great  changes,  let  it  be  understood,  are  influ- 
enced by  many  diverse  conditions.  They  may  be  premature  or 
retarded,  rapid  or  slow,  intense  or  attenuated,  according  to  tem- 
perament, race,  climate,  nutrition,  heredity,  sex,  and  social  conditions. 

PERIOD  PRECEDING  PUBERTY. 

Body. — Following  the  steadily  progressive  gro^^i:h  of  later  child- 
hood up  to  about  the  age  of  ten  in  girls  and  twelve  in  boys,  the  general 
development  of  the  body  seems  for  a  year  or  two  to  be  reduced  to  the 
minimiun,  as  if,  during  this  time.  Nature  were  trying  to  gather  strength 


852  PUBERTY 

for  the  increased  rate  of  growth  which  is  to  follow.  According  to  the 
available  statistics  of  different  nations,  this  limitation  affects  the 
height,  weight,  and  bony  system  (thorax,  skull,  pelvis,  extremities), 
as  well  as  muscular  development.  Limitation  of  growth  seems  to  be 
the  general  law  for  this  period,  and  probably  holds  equally  true  con- 
cerning the  internal  organs,  although  this  has  not  been  definitely 
proven  except  in  the  case  of  the  liver. 

Toward  the  close  of  this  phase  of  life  a  rapid  lengthening,  espe- 
cially of  the  lower  extremities,  takes  place.  The  growth  of  the  trunk 
is  retarded,  while  that  of  the  thorax  is  hardly  perceptible;  therefore 
the  respiratory  capacity  and  the  size  of  the  heart  as  compared  with 
the  height  are  less  than  at  any  later  time.  As  the  weight,  too,  increases 
but  slowly,  boys  and  girls  of  this  age  are  apt  to  look  ungainly,  long 
legs,  a  short  trunk,  and  leanness  being  their  most  striking  physical 
characteristics.  This  puerile  type,  as  A.  Delpeuch  calls  it,  seems 
essentially  to  be  identical  with  that  of  the  so-called  tuberculous 
diathesis.  One  cannot  but  wonder  whether  those  who  subsequently 
contract  tuberculosis  retain  their  puerile  proportions,  and  are  thereby 
predisposed  to  the  disease,  or  whether  the  failure  to  acquire  the  adult 
conformation  is  not  really  the  effect  of  latent  tuberculosis. 

Mind. — Emerging  from  a  period  of  mere  imitation,  the  little  boy  or 
girl  toward  puberty  begins  to  exercise  the  power  of  reason.  The 
knowledge  which,  before  this  time,  has  been  merely  stored  in  the 
memory  mechanically  is  now  utilized  by  the  mind  in  forming  ideas, 
in  comparing,  and  in  generalizing.  Reason  and  judgment,  hitherto 
impersonal,  become  original,  more  correct,  and  more  definite.  The 
attention  is  more  concentrated,  reflection  is  clearer,  imagination  is 
curbed,  and,  as  the  sexual  instinct  awakens,  the  affections  become 
sweeter  and  more  intense.  The  feelings,  less  impulsive,  are  better 
controlled  by  a  will  which  now  asserts  itself.  All  these  different 
mental  activities  produce  a  more  stabile  equilibrium.  Discipline  is 
more  readily  borne;  behavior,  the  power  of  application  to  work,  and 
work  itself  are  improved.  The  teacher  congratulates  himself  upon 
the  changes  brought  about,  and  parents  see  with  satisfaction  the 
happy  modifications  in  the  character  of  their  child. 

PUBERTY. 

Body. — This  preparatory  period  is  followed  by  the  most  critical 
and  interesting  phase  of  life,  i.  e.,  puberty.  Up  to  this  time  the  child 
has  shown  only  racial  instincts,  but  he  now  begins  to  develop  indivi- 
dual characteristics,  and  famil^^  traits  become  accentuated.  A  rapid 
development  of  the  organism  as  a  whole  sets  in,  not  gradually,  but 
by  leaps  and  bounds.  Height  and  weight  increase^  the  muscles 
develop,  the  general  bony  system  enlarges,  and  all  the  viscera  seem  in 
haste  to  acquire  adult  formation.  Coincident  with  this  period  is  the 
sudden  development  of  all  the  organs  of  generation,  and  the  forcing 
of  their  functions,  some  of  which  now  appear  for  the  first  time. 


PUBERTY  853 

There  are  no  fixed  rules  as  to  the  order  in  which  these  changes  take 
place;  in  fact,  they  appear  in  almost  endless  variety,  according  to 
the  influences  of  climate,  race,  sex,  heredity,  and  environment.  For 
this  reason  it  does  not  seem  quite  correct  to  reckon  puberty  from  the 
development  of  a  single  system  of  the  body — for  example,  the  repro- 
ductive. Ovulation  or  the  forming  of  mature  spermatozoa  does  not 
alone  make  a  mature  woman  or  man,  but  that  combination  of  physical 
and  psychical  development  which  Nature  at  this  time  brings  about, 
and  which  is  designated  as  puberty  proper.  The  length  of  the  period 
is  variable;  but  in  this  country  the  time  between  the  tw^elfth  and 
fourteenth  years  in  girls  can  be  accepted  as  the  average.  Boys  pass 
more  gradually  into  adolescence,  usually  between  the  ages  of  fourteen 
and  sixteen. 

As  to  the  details  of  physical  development,  we  find  that  growth  in 
height  usually  precedes  by  a  few  years  the  pronounced  increase  in 
weight  which  takes  place  during  puberty.  After  a  time  of  slow  growth 
during  late  childhood,  girls  grow  more  rapidly  from  their  eleventh  or 
twelfth  year  to  their  fifteenth  year,  while  increase  in  weight,  marked 
between  the  thirteenth  and  fifteenth  years,  sets  in  and  continues, 
although  much  more  slowly,  until  the  age  of  twenty.  Boys  increase 
decidedly  in  height  between  fourteen  and  seventeen,  with  the  maxi- 
mum around  the  fifteenth  year,  but  no  remarkable  gain  in  weight 
occurs,  as  a  rule,  until  sixteen  or  seventeen.  Speaking  generally,  we 
may  say  that  until  eleven  years  of  age  boys,  and  from  then  until  fifteen 
years  of  age,  girls  exceed  the  other  sex  in  weight  and  height;  after 
fifteen  or  sixteen  years  of  age  girls  again  fall  behind. 

Corresponding  with  the  general  growth  the  shoulders  broaden  and 
the  bony  thorax  enlarges  markedly — as  much  as  five  inches  in  three 
years — making  room  for  the  increasing  pulmonary  development 
which  oftentimes  raises  the  maximum  capacity  by  500  c.c.  In  girls, 
even  in  those  who  wear  no  corset,  it  is  chiefly  the  upper  thoracic  por- 
tion which  enlarges,  the  lower  costal  region  developing  much  more 
slowly;  therefore  the  girl's  breathing  tends  to  the  costal  type  while 
the  young  man's  respiration  is  usually  of  the  abdominal  type. 

The  circumference  of  the  head  keeps  pace  with  the  general  develop- 
ment; in  girls  between  the  eleventh  and  thirteenth  years  it  is  greater 
than  in  boys,  before  and  after  this  age  smaller.  The  bony  pelvis  widens 
more  in  girls,  its  greatest  growth  taking  place  between  eleven  and 
fourteen  years,  as  compared  with  thirteen  to  sixteen  in  boys.  Yet 
even  at  fifteen  or  sixteen  the  female  pelvis  surpasses  that  of  the  male 
in  size,  and  is  evidently  prepared  for  possible  gestation.  Muscular 
development,  naturally  greater  in  boys,  reaches  its  maximum  between 
fourteen  and  sixteen  years  in  girls  and  fifteen  to  eighteen  in  boys. 
The  flesh  is  firmer  and  harder  in  the  latter,  while  in  the  former  it  is 
infiltrated  with  fat,  which  serves  to  give  to  the  body  a  rounded  and 
graceful  contour. 

Larynx. — In  girls  the  voice  rarely  breaks,  but,  on  the  contrary, 
becomes  fuller  and  more  resonant,  the  larynx  enlarging  chiefly  in  its 


854  PUBERTY 

vertical  diameter.  In  hoys  the  transverse  diameter  increases  most, 
the  vocal  cords  are  lengthened,  and  the  voice,  after  a  period  dm-ing 
which  it  "cracks,"  is  permanently  pitched  an  octave  lower  than 
before. 

How  intimately  this  and  other  developmental  changes  are  related 
to  the  imier  secretion  of  the  organs  of  generation  (testicles)  is  demon- 
strated by  boys  emasculated  before  puberty.  Their  voices  remain 
high,  they  are  slender  and  narrow  chested,  their  pelves  are  broad,  and 
there  is  little  growth  of  hair  except  on  the  scalp. 

Thyroid  Gland. — No  less  important  is  the  decided  influence  which 
the  th\Toid  gland  exerts  upon  the  growth  of  the  whole  bony  system, 
and  especially  on  the  genital  system  of  both  sexes.  In  about  15  per 
cent,  of  girls  this  gland  becomes  swollen  at  puberty,  and  in  60 
per  cent,  is  temporarily  enlarged  when  menstruation  appears. 

Hair. — \Mien  hair  appears  on  the  previously  smooth  body  puberty 
is  imminent.  In  girls  a  sparse  groT\^h  begins  to  show  a  few  months 
before  menstruation,  first  on  the  pubes,  but  gradually  covering  the 
genitalia  and  axillae.  In  boys  from  fourteen  to  sixteen  years  of  age 
it  may  also  appear  over  the  chest  and  back,  the  extensor  surfaces 
of  the  extremities,  and  upon  the  upper  lip,  cheeks,  and  chin.  The 
growth  of  the  beard  is,  however,  not  coincident  with  puberty;  in 
fact,  in  some  races  this  is  altogether  lacking. 

Circulatory  System. — The  sudden  acceleration  of  development  at 
puberty  may  cause  undue  strain  on  the  heart,  and,  perhaps,  a  dis- 
proportionate development  of  body,  heart,  and  bloodvessels.  Hence, 
in  spite  of  the  fact  that  cardiac  growth  is  greater  during  puberty  than 
during  preceding  years,  irregular  and  feeble  pulse,  palpitation,  short- 
ness of  breath,  and  vertigo  are  frequently  complained  of,  while  vaso- 
motor instability  is  evidenced  by  blushing,  angioneuroses,  and  func- 
tional albuminuria. 

The  Genitalia. — Decided  changes  now  take  place  in  the  genital  sys- 
tem. The  organs  become  more  vascular,  rapidly  increase  in  size, 
and  mature  within  two  years,  whereas  three  or  four  years  must  elapse 
before  adolescent  weight  and  height  are  attained.  In  girls  the  labia 
majora  hj^pertrophy  and  completely  cover  the  vagina;  the  clitoris 
and  the  anterior  part  of  the  labia  minora  also  increase  in  size,  the 
former  becoming  erectile,  and  the  vagina  turgescent  and  more 
capacious. 

From  a  cylindrical  shape  the  uterus  changes  to  the  adult  form,  with 
larger  and  flattened  fundus;  its  muscular  walls  and  mucous  lining 
thicken  considerably,  and  numerous  glands  develop. 

The  o^'aries  double  their  weight  from  |  to  1  dram,  and  twelve 
to  fifteen  Graafian  follicles  gradually  approach  the  surface,  ready  to 
enlarge  and  burst  in  tiu-n  at  Natiue's  call.  ]More  or  less  coincident 
with  these  transformations  is  enlargement  of  the  breasts  which  causes 
transient  pricking  sensations,  sometimes  even  painful  tension  and 
twinging  pains  along  the  ribs. 

Abdominal  heaviness  and  a  sense  of  pressure  are  felt  in  the  pelvis, 


PUBERTY  855 

also  tenderness  on  palpation  over  the  hypogastrium;  occasionally 
there  are  flashes  of  heat,  congestion  of  the  face,  and  not  infrequently, 
epistaxis,  general  lassitude,  and  sacral,  iliac,  or  lumbar  pains  which 
radiate  to  the  thighs. 

Gastro-intestinal  disturbances,  such  as  anorexia,  dyspepsia,  and 
constipation,  as  well  as  nervous  palpitations,  insomnia,  accelerated 
respiration,  and  increased  perspiration,  may  all  be  noted.  The  girl 
is  often  irritable,  extremely  emotional,  and  feels  unfit  for  work. 

In  this  period  between  the  twelfth  and  sixteenth  years,  when  the 
whole  genital  apparatus  is  turgescent  and  the  vital  functions  at  high 
tide,  the  first  menstruation  occurs,  lasts  sometimes  but  a  few  hours, 
usually  for  a  day  or  two,  and  ends  with  the  liberation  of  the  first  ovum 
and  a  loss  of  blood  less  than  that  normally  lost  by  the  mature  woman 
(3  to  6  fluidounces).  After  a  few  months  the  menses  become  regular 
and  the  procreative  faculty  is  fully  established. 

Genital  development  takes  place  a  little  later  in  boys  than  in  girls. 
After  the  first  curly  hair  appears  on  the  external  genitalia,  the  scrotum 
considerably  increases  in  size  and  in  pigment,  and  its  sudorific  secre- 
tion becomes  more  noticeable.  Cowper's  glands,  the  prostate,  the 
seminal  vesicles,  and  the  testicles  rapidly  approach  the  adult  size. 
At  this  time  nocturnal  emissions  occur,  and  may  sometimes  be  pain- 
ful. At  first  they  may  contain  no  spermatozoa;  after  the  fifteenth 
year,  spermatozoa  are  present,  and  recur  at  more  or  less  regular 
intervals. 

Boys  pass  into  adolescence  more  gradually,  and  always  later,  than 
girls,  other  conditions  being  equal.  Many  factors  influence  the  begin- 
ning of  puberty.  With  few  exceptions,  it  occurs  earlier  the  higher 
the  mean  atmospheric  temperature.  An  increase  in  heat,  even  when 
it  lasts  but  a  short  time,  causes  more  rapid  growth,  and  a  retardation 
of  development  has  been  observed  after  a  fall  in  temperature.  For 
instance,  growth  during  the  winter  months  is  only  slight,  during  spring 
and  summer  it  is  more  rapid,  particularly  in  height,  while  autumn 
brings  a  more  decided  gain  in  weight. 

A  sanguine  or  nervous  temperament,  large  stature,  strong  constitu- 
tion, hereditary  tendency  to  precocity,  city  life,  an  environment  of 
affluence,  the  use  of  alcohol,  and  premature  sexual  relations — all 
induce  early  puberty. 

Latin  races  mature  earlier  than  Anglo-Saxons.  Those  who  grow 
up  in  poverty  lag  behind  in  weight  and  stature,  the  period  of  limited 
growth  just  before  puberty  being  prolonged  and  puberty  retarded, 
but  full  development  is  attained  at  about  the  same  age  as  among  the 
well-to-do. 

Mind. — ^At  puberty  not  only  the  body,  but  also  the  mind,  passes 
through  a  crisis,  the  accompanying  psychical  phenomena  of  which 
are,  unfortunately,  often  regarded  with  indifference  or  skepticism, 
whereas,  in  the  interests  of  sound  and  harmonious  development  they 
should  receive  the  most  careful  consideration.  The  period  is  character- 
ized by  general  restlessness  and  a  certain  instability  of  mind,  vague 


856  PUBERTY 

aspirations  rather  than  concrete  thought  dominating  the  mind. 
There  is  an  ardent  desire  for  knowledge.  Rhythm  and  music,  dramatic 
roles  and  poses,  give  exquisite  pleasure,  but  the  critical  faculties 
seem  to  be  more  or  less  dormant.  It  is  the  age  of  ideals,  of  hopes  and 
tender  sentiment,  of  folly  and  imitation,  of  self-consciousness  and 
over-sensitiveness.  There  is  a  proneness  to  exaggeration.  Feehngs 
change  like  the  pictures  of  a  kaleidoscope;  to  use  Marfan's  apt 
expression,  we  see  a  mind  in  revolt.  Girls  no  longer  mix  so  indis- 
criminately as  before,  sexual  characteristics  reveal  themselves,  and 
inherited  traits,  good  or  bad,  become  more  conspicuous.  A  trait 
wholly  absent  at  this  time  is  not  likely  afterward  to  appear. 

The  girl's  natural  grace  is  enhanced,  her  love  of  dress  intensified, 
she  studies  the  art  of  pleasing.  At  the  same  time  her  inborn  qualities 
become  more  pronounced,  timidity  merges  into  love  of  solitude — - 
even  shyness — natural  kind-heartedness  becomes  unduly  tender, 
even  eager  for  unnecessary  sacrifice.  Early  pride  turns  into  haughti- 
ness, indolence  into  laziness,  the  innocent  ruse  of  former  days  buds 
into  deception,  a  good  entertainer  becomes  an  incessant  chatterbox. 
Highly  sensitive,  capricious,  full  of  temper,  tricks,  and  pranks,  now 
exuberant,  now  cast  down,  passing  from  laughter  to  tears  more  quickly 
than  sunshine  to  rain  on  an  April  day — such  a  girl  is  difficult  to  manage 
in  school  or  house,  and  taxes  the  patience  of  a  saint.  Yet,  after  all, 
her  faults  are  of  passive  type,  as  compared  with  those  of  boys. 

Just  as  his  physical  development  is  more  or  less  out  of  proportion 
during  the  period  of  his  most  active  growth,  so  the  average  adolescent 
boy  is,  in  a  psychical  sense,  an  inharmonious  personality.  He  is 
wiser  than  his  teacher,  more  experienced  than  his  parents — more 
gritty,  more  witty — in  fact,  a  superior  being.  He  readily  becomes 
hypersensitive,  argumentative,  contrary,  overbearing,  authoritative, 
contradicting  others  and  himself  at  every  instant.  His  chief  charac- 
teristics seem  singularly  accentuated,  almost  to  the  point  of  being 
caricatures.  He  has  more  than  the  ordinary  self-respect,  self-reliance, 
self-consciousness.  If  naturally  benevolent,  he  makes  Utopian  plans 
to  help  the  whole  world.  If  a  good  mixer,  he  is  liable  to  become  an 
inveterate  talker,  or  Miinchhausen.  His  natural  cheerfulness  borders 
on  hilarity,  and  a  livel}^  disposition  may  become  impulsive,  violent, 
or  even  brutal. 

General  Health. — The  general  health  at  puberty  is  subject  to  many 
variations  for  the  simple  reason  that,  in  addition  to  the  diseases  due 
to  ordinary  etiological  factors,  the  physiological  changes  which  now 
occur  may  become  pathological  if  the  general  development  is  too  sud- 
den, or  so  disproportionate  as  to  leave  certain  organs  too  weak  for 
the  increased  amount  of  work  now  demanded  of  them.  While  statistics 
show  that  in  middle-grade  schools  the  morbidity  among  boys  is  30  per 
cent.,  and  as  high  as  50  per  cent,  in  girls,  the  mortality  is  compara- 
tively very  low.  Nevertheless,  disturbances  (functional  as  well  as 
organic)  should  receive  the  closest  attention,  because  neglect  at  this 
time  may  be  responsible  for  sequelae  that  will  persist  throughout  life. 


PUBERTY  S57 

Therefore  the  physiological  and  psychical  development  of  growing 
boys  and  girls  should  be  carefully  watched  that  we  may  guide  them 
safely  through  the  Scylla  and  Charybdis  of  puberty.  Insufficient 
nourishment,  uncleanliness,  unliygienic  surroundings,  including  bad 
light  as  well  as  bad  air,  a  sedentary  life,  and  faulty  posture,  are  no 
doubt  now,  as  at  any  other  period  of  life,  baneful  conditions.  More- 
over, it  is  certain  that  physical  overwork  which  lowers  the  general  resis- 
tance, the  overtaxing  of  the  functional  activity  of  immature  organs 
(such  as  the  heart,  lungs,  or  kidneys),  and  mental  strain  upon  the 
nervous  system,  the  heart,  respiration,  muscular  strength,  and  nutri- 
tion, are  in  a  special  sense  predisposing,  provocative,  and  aggravating 
etiological  factors  at  puberty.  The  necessity  of  protecting  young 
boys  and  girls  against  them  at  a  time  when,  stirred  by  new  sensations 
and  ambitions,  they  are  apt  to  go  beyond  their  strength  in  competi- 
tion with  others  on  the  athletic  field  or  in  the  class-room,  cannot  be 
sufficiently  emphasized. 

Schlossmann  and  Pfaundler  noted  that  of  600  cases,  more  or  less 
closely  connected  with  puberty,  20  per  cent,  suffered  from  disturb- 
ances accompanying  menstruation,  15  per  cent,  from  cardiac  neuroses, 
10  per  cent,  from  goitre,  15  per  cent,  from  periodical  headache,  13 
per  cent,  from  neurasthenia,  13  per  cent,  from  hysteria,  6  per  cent, 
from  epilepsy,  4  per  cent,  from  chorea,  and  5  per  cent,  from  the 
albuminuria  of  adolescence. 

The  mortality  from  tuberculosis,  according  to  Kirchner,  increases 
in  boys  from  10  to  16,  and  in  girls  from  18  to  26  deaths  to  100  total 
deaths.  As  disturbances  of  special  organs  are  treated  under  their 
respective  headings,  we  shall  merely  enumerate  them  rapidly,  accord- 
ing to  the  system  principally  aft'ected : 

Skeleton. — Faulty  position  and  excessive  unilateral  exercise,  as, 
for  instance,  in  playing  the  violin  or  in  tennis,  may  cause  curvature 
of  the  spine,  especially  when  the  osseous  skeleton  is  insufficiently 
firm,  and  the  muscles  are  weak  from  lack  of  nutrition  and  harmonious 
exercise.  Genu-valgum  may  develop  from  long-continued  standing. 
So-called  "  growing  pains"  are  probably  in  most  cases  due  to  infection, 
overexertion,  or  slight  trauma.    Osteitis  and  periostitis  are  infrequent. 

Skin  and  Muscles. — Nevi,  previously  unnoticed,  may  enlarge  at 
puberty.  Eczema,  urticaria,  seborrhea,  and  acne  seem  to  be  more 
frequent  as  the  general  growth  becomes  more  rapid.  As  regards 
muscles,  myositis,  torticollis,  and  the  juvenile  forms  of  muscular 
atrophy  or  dystrophy  may  occur. 

Circulatory  System. — Cardiac  disease,  especially  mitral  stenosis, 
often  previously  unsuspected,  manifests  itself  at  puberty,  while  sys- 
tolic murmurs  over  the  apical  and  pulmonary  areas,  palpitation, 
arrhythmia,  tachycardia,  vertigo,  and  syncope  may  appear  transi- 
torily, and  disappear  with  progressive  development.  It  is  sometimes 
difficult  to  distinguish  these  murmurs  from  permanent  changes, 
therefore  the  prognosis  should  always  be  guarded. 

The  vasomotor  system  is  ill-balanced;  and  disproportions  between 


858  PUBERTY 

the  heart,  bloodvessels,  and  body  may  now  be  observed.  Girls  are 
especially  predisposed  to  chlorosis;  according  to  some  writers  this 
deficiency  of  hemoglobin  in  the  circulating  blood  is  the  result  of 
Nature's  effort  to  prepare  for  a  possible  pregnancy  by  storing  in  the 
liver  iron  from  the  blood.  This  form  of  anemia,  as  well  as  others 
following  tuberculosis,  kidney  affections,  excessive  exercise,  and 
repeated  severe  hemorrhages,  or  due  to  undernourishment,  should 
receive  prompt  treatment  so  that  harmonious  development  be  not 
retarded. 

Respiratory  System. — A  peculiar  relationship  exists  between  the 
genital  organs  and  the  Schneiderian  mucous  membrane  which  finds 
expression  in  the  so-called  nasal  asthma  and  corj^za  of  puberty.  Con- 
trary to  former  belief,  adenoid  growths  may  persist,  and  shoidd  be 
removed  in  every  case.  Attacks  of  angina,  also  of  tonsillitis  with  its 
train  of  s\Tnptoms,  are  common.  Spasm  of  the  glottis,  aphonia,  and 
croupy  cough  appear  m  laryngeal  affections.  If  the  voice  breaks,  the 
vocal  cords  need  a  period  of  rest  and  should  not  be  unnecessarily 
strained  by  shouting  or  efforts  at  loud  singing.  At  puberty  the 
asthmatic  attacks  which  accompany  bronchitis  during  childhood 
often  absolutely  cease. 

Digestive  System. — Disturbances  of  digestion  are  common  at 
puberty,  especially  when  there  is  a  tendency  to  overeat  or  to  bolt 
the  food.  Dyspepsia  due  either  to  excessive  or  deficient  secretion  of 
hydrochloric  acid,  and  even  of  the  atonic  or  nervous  type,  is  rather 
frequent,  particularly  in  girls.  Constipation,  colic,  and  mucomem- 
branous  enterocolitis  are  quite  common.  If  the  contents  of  the  bladder 
and  rectum  are  habitually  or  abnormally  long  retained  (sometimes 
from  false  modesty),  anteflexion  or  retroversion  of  the  uterus  may 
result;  while  faulty  corsets  and  tight  skirt  bands  are,  no  doubt,  causa- 
tive factors  of  visceral  ptosis,  especially  when  there  is  a  tendency  to 
relaxation  of  the  abdominal  viscera. 

Diseases  of  the  Urinary  Organs. — Diseases  of  the  urinary  organs 
are  rare.  Orthostatic  albuminuria  usually  disappears  with  adoles- 
cence, enuresis  in  girls  with  the  establishment  of  menstruation,  and 
in  boys  when  the  prostate  has  attained  such  size  as  materially  to 
assist  in  the  retention  of  urine. 

Nervous  System. — The  nervous  system  of  a  healthy  young  person  at 
puberty  may  present  changes  which  at  other  times  would  be  con- 
sidered distinctly  pathological,  and  parents  and  teachers  need  keen 
insight  and  great  powers  of  forbearance  at  this  critical  period  of  rapid 
physiological  development.  Evidences  of  inherited  disease,  as,  for 
instance,  general  nervousness,  hemicrania,  hysteria,  latent  syphilis, 
and  general  paresis,  or  the  early  mental  weakness  of  dementia  precox, 
may  be  noticed  for  the  first  time.  Epilepsy  rarely  decreases,  but  is 
almost  always  aggravated  to  the  adult  t^^pe,  or  it  may  now  appear. 

Pressure  sensations,  languor,  pain  in  the  back,  sleeplessness,  and 
the  easily  induced  exhaustion  of  neiu-asthenia  may  often  be  over- 
looked at  a  time  when  neuralgia,  cephalalgia,  a  state  of  apathy,  and 


PUBERTY  859 

even  indolence,  are  so  common.  Disturbances  of  sight  manifest 
themselves  in  many  ways,  but  probably  do  not  depend  upon  pubescent 
changes.  The  senses  of  smell  and  of  taste  (pica)  are  sometimes  per- 
verted, and  often  aural  noises  are  complained  of  temporarily. 

The  phenomena  of  puberty  may  come  on  prematurely  as  regards  the 
body  or  mind;  for  instance,  menstruation  and  pregnancy  have  been 
reported  in  girls  eight  and  nine  years  old.  In  boys  sexual  and  physical 
development  are  largely  coordinate,  although  in  exceptional  cases 
repeated  seminal  emissions  have  occurred  in  early  childhood.  Delayed 
menstruation — that  is,  true  amenorrhea  (as  differentiated  from 
atresia  of  the  uterovaginal  canal) — may  be  caused  by  congenital  heart 
disease  or  dystrophy  of  the  ovaries  and  uterus,  the  latter  being  usually 
found  in  conjunction  with  undeveloped  breasts  and  lack  of  pubic 
hair. 

A  functional  form  of  amenorrhea  with  anemia,  neuroses,  and  psy- 
choses, is  not  infrequent  after  an  acute  infectious  disease,  or  after 
sudden  changes  of  climate,  while  vicarious  menstruation  may  occur 
periodically  from  any  mucous  membrane.  Before,  during,  and  after 
menstruation  itself,  there  are  often  colicky  pains,  gastro-intestinal 
disturbances,  headache,  vertigo,  angioneuroses,  flashes  of  heat,  and 
urticaria.  Leucorrhea,  malposition  of  the  uterus,  or  inflammation  of 
its  appendages  may  become  manifest  or  aggravated  at  puberty. 
Other  disturbances,  such  as  dysmenorrhea,  metrorrhagia,  or  inflam- 
mation of  the  mammary  glands,  are  not  uncommon. 

In  boys,  also,  at  this  phase  of  life  the  breasts  may  become  affected, 
and  occasionally  a  sensitive  swelling  appear  in  one  or  both,  possibly 
accompanied  by  pain  and  redness,  which  disappear  spontaneously 
within  a  short  time.  Circumcision  may  become  necessary  for  phimo- 
sis, which  leads  to  enuresis,  masturbation,  or  balanitis  from  accumula- 
tion of  smegma.  Urethritis  and  orchitis — the  latter,  as  a  rule,  of 
tuberculous  origin — are  not  rare.  Undescended  testicles  may  in  time 
from  pressure,  especially  when  arrested  in  the  inguinal  canal,  cause 
painful  sensations,  and,  unless  they  can  be  restored  to  their  proper 
place  either  by  operation  or  a  suitable  pad,  their  removal  should  be 
considered  on  account  of  the  danger  of  atrophy  or  malignant  degen- 
eration. 

Glands. — The  consequences  of  absence  of  testicular  secretion,  as 
illustrated  by  young  eunuchs;  the  neuroses  and  psychoses  of  ovarian 
dystrophy,  acromegaly,  gigantism,  and  infantilism  observed  in  con- 
nection with  disturbances  of  the  infundibular  gland;  the  influence 
of  the  thyroid  upon  physical  and  mental  characteristics;  the  exag- 
geration of  convulsive  phenomena  in  suprarenal  insufficiency — have 
all  been  so  forcibly  brought  to  light  in  recent  investigations  that  their 
mere  enumeration  impresses  us  with  the  immense  importance  of  the 
internal  secretions.  The  glands  producing  them  seem  to  be  especially 
active  at  puberty;  therefore,  a  disturbance  of  their  function  at  or 
before  this  time  must  exert  a  far-reaching  influence  upon  development 
in  general. 


860  PUBERTY 

This  chapter  would  be  incomplete  without  mention  being  made  of 
masturbation,  a  pathological  condition  doubtless  chiefly  due  to 
inherited  weakness  of  the  will.  The  inclination  for  it  is  marked  in 
the  mentally  deficient,  in  epileptics,  and  in  idiots.  Occasionally 
epidemics  of  it  break  out  in  schools.  It  is  true  that  with  the  awaken- 
ing of  the  sexual  impulses,  phimosis,  vulvitis,  eczema,  accumulations 
of  smegma,  vesical  calculi,  constipation,  and  similar  conditions,  by 
irritating  the  genital  nerves,  may  be  the  exciting  cause.  Such  local 
conditions  should,  therefore,  in  due  time  receive  proper  attention. 
Harm  does  not  necessarily  follow  occasional  self-abuse;  but,  if  habit- 
ually indulged  in,  general  nervousness,  listlessness,  exhaustion,  car- 
diac palpitation,  migraine,  absent-mindedness,  loss  of  memory,  dis- 
inclination for  work,  and  anemia  may  result,  and,  what  seems  worse, 
still  further  weakening  of  the  will.  Boys  more  easily  fall  victims  to 
this  habit  than  girls.  Plain,  non-stimulating  diet,  plenty  of  physical 
exercise,  the  avoidance  of  all  incentives  to  sexual  passion  in  literature, 
art,  and  association,  with  the  correction  of  the  physical  factors  men- 
tioned, and  a  plain  heart-to-heart  talk  with  a  sensible  sympathetic 
teacher  or  parent  will  be  of  more  benefit  than  criticism  or  open  rebuke. 


INDEX 


Abdomen,  boat-shaped,  822 

concave,  306 

distention  of,  297,  556,  621 

dragging  sensation  in,  494 

fluid  in,  357 

neuralgia  in,  266 

protuberant,  357 

rigidity  of,  337,  353 

tapping  of,  356,  384 
Abdominal  band,  use  of,  23,  358 

cavity,  testes  in,  97 
Abortion  due  to  syphilis,  739 
Abscess,  alveolar,  249 

amebic,  of  liver,  378 

anal,  367 

cold,  518,  524 

ischiorectal,  367 

of  appendix,  336,  341 

of  brain  in  mastoiditis,  615 

of  joint,  523 

of  kidney,  551,  565 

of  lymph  gland,  498 

of  spleen,  494 

pulmonary,  408,  442 

retroesophageal,  232 

retropharyngeal,  609,  658,  726 

subphrenic,  379,  380 

tuberculous,  519 
Absorption  of  hypertrophy,  310 
Acarus  scabiei,  604 
Accommodation,  power  of,  43 
Acetone  bodies,  198 
Acetonuria,  529 
Achondroplasia,  cretinistic,  138 

distinguished  from  cretinism,  513 
from  rickets,  238 
Acid  fermentation,  intestinal,  196 

intoxication,  268 
Acidosis,  199,  206 

acetonemic,  529 

cause  of  vomiting,  265 
Acids,  fatty;  in  mother's  milk,  200 

ingestion  of,  276 
Addison's  disease,  514 

operation  for,  516 
treatment  of,  515 
Adenectomy,  399 
Adenitis,  cervical,  496,  650 

simple  acute,  495 

from  bacteria,  496 
symptoms  of,  496 
chronic,  497 


Adenitis,  treatment  of,  496 

tuberculous,  496,  650,  732 
Adenocarcinomata  of  liver,  388 
Adenoids,  396,  496,  612 

at  puberty,  858 

cause  of  cough,  438 
of  enuresis,  537 
of  rhinitis,  393 

effects  of,  397 

in  chorea,  846 

in  idiots,  835 

removal  of,  216,  613 

treatment  of,  398 
Adenoma,  renal,  558 
Adenosarcoma  of  kidney,  556 
Adiposity  in  child,  516 
Adolescence,  853 

rickets  in,  245 
Adrenal  glands,  514 

tuberculosis  of,  515 
Adrenalin  in  hemorrhage,  127,  396 

in  pertussis,  695 
Adrenals  in  Addison's  disease,  515 

tumors  of,  514 
Agenesis  corticalis,  105 
Air,  change  of,  693 

fresh,  for  infants,  25 

in  treating  disease,  212 
Air-borne  disease,  639 
Air  passages,  infection  of,  423 

narrowing  of,  742 
Albumin  in  milk,  173,  271 

water,  284 
Albuminuria  at  birth,  111 

cyclic,  527 

functional,  527 

in  diphtheria,  660,  668 

lordotic,  527 

of  adolescence,  857 

orthostatic,  527,  858 

paroxysmal,  528 

postural,  527 
Alcohol  in  bronchopneumonia,  430 

in  diarrhea,  286 

in  nephritis,  545 

in  pneumonia,  421 

a  poison  to  children,  59 
Alcoholic  neuritis,  839 
Alcoholism  among  women,  59 

cause  of  cirrhosis,  381 
of  hare-lip,  82 
of  idiocy,  832 
Alexins,  166 
Alimentary  intoxication,  207 


862 


INDEX 


Alkalies  in  acidosis,  529 

ingestion  of,  276 

in  intestines,  199 
Alkaline  diluents,  150 
AUantois,  bursting  of,  96 
Alopecia  areata,  598,  599 

forms  of,  598 
Alpine  plants,  experiments  upon,  70 
Altitudes,  high,  215 
Alzheimer  method,  777 
Amaurotic  family  idiocy,  832 
Ameba  coli  in  dysentery,  291 
Amenorrhea,  true,  859 
Amino-acids,  192 
Amylase,      pancreatic     and      salivary, 

191 
Amyloid  disease  of  intestines,  334 
of  kidney,  547,  548 

liver,  384 
Amylopsin,  193 

Amyotrophic  lateral  sclerosis,  796 
Anaphylaxis,  675,  680 
Anemia,  475 

at  puberty,  858 

blood  picture  in,  476 

cause  of  heart  murmur,  449 

due  to  worms,  341,  348 

etiology  of,  475 

fatal,  from  jaundice,  374 

from  pleural  effusion,  433 

hemoglobin  in,  472 

in  familial  jaundice,  373 

in  rickets,  242 

lymphatic,  484 

pernicious,  478 

primary,  476 

secondary,  475,  482,  484,  491 

simple,  475,  495 

simulated  by  malaria,  735 

splenic,  483 

syphilitic,  746 

treatment  of,  476,  482 
Anencephalia,  80 
Anesthesia  for  adenectomy,  399 

in  thymic  disease,  508 

local,  508 
Angina,  scarlatinal,  634 
Angioma,  600 

Animal  heat  of  body,  154,  155 
Ankylosis,  bony,  522 
Ankylostomum  duodenale,  348 
Anthrax     differentiated      from     noma, 

259 
Antibodies  in  the  blood,  120,  167,  612, 

689 
Antiseptics,  intestinal,  287 

urinary,  568 
Antitoxin,  administration  of,  678,  679 

as  specific  in  diphtheria,  679 

diphtheria,  649,  651,  660 
action  of,  677 
caution  in  use  of,  680 
early  administration  of,  672 
production  of,  677 

dosage  of,  679 

effects  of,  on  mortality,  679 


Antitoxin  eruptions,  682 

followed  by  death,  600 

injection,  inode  of,  679 

in  pseudodiphtheria,  687 

intravenously,  673 

limitations  of,  678 

reaction  of,  678 

sequelae  of,  680 

tetanus,  134 
Anuria,  532 

from  atresia  of  urethra,  104 
Anus,  absence  of,  94 

artificial,  93 

care  of,  26 

diseases  of,  361 

eczema  of,  366 

fissure  of,  365 

fistula  in,  367 

imperforate,  326 

inspection  of,  363,  365 

itching  of,  345 

malformation  of,  94 

prolapse  of,  362 

stricture  of,  329 
Aorta,  hyperplasia  of,  507 
Aortic  disease,  463 

insufficiency,  463 

regurgitation,  459 

stenosis,  454,  459 
Apex  beat,  48,  446,  454 
Aphasia,  625 
Aphonia,  837 
Aphthai,  Bednar's,  250 
Appendectomy,  340 
Appendicitis,  335 

acute,  forms  of,  336 

bacteria  a  cause  of,  336 

catarrhal,  337 

chronic,  336,  339 

differentiated    from    infected 
glands,  727 

diagnosis  of,  339 

differentiation  of,  339,  623 

gangrenous,  338 

interval  operation  in,  340 

lesions  in,  337 

suppurative,  336,  340 

treatment  of,  340 

ulcerative,  336,  338 

vomiting  in,  264 
Appendix,  anomalies  of,  336 

perforation  of,  336,  338 

position  of,  335 

rupture  of,  338 
Appetite,  capricious,  333 

in  chronic  gastritis,  296 

ravenous,  306,  830 
Aprosexia,  398 
Arm,  palsy  of,  109 
.  Arnold  steam  sterilizer,  144 
Arrhythmia,  447,  462 
Arsenical  neuritis,  839 
Arteries  in  diphtheria,  668 

of  newborn  infant,  19 

vasomotor  tone  of,  446 
Artery,  pulmonary,  dilated,  453 


INDEX 


863 


Artery,  umbilical,  bleeding  from,  126 
Arthritis,  acute,  of  infants,  522 

deformans,  759,  781 

from  vulvovaginitis,  578 

gonorrheal,  753 

pneumococcal,  753 

rheumatoid,  759 

scarlatinal,  635,  753 

syphilitic,  523,  754,  761 

tuberculous,  524,  753 
Artificial  feeding,  178 

indigestion  from,  267,  317 

respiration,  114 
Ascaris  lumbricoides,  346 
Ascites,  356 

chylous,  356,  357 

fluid  in,  composition  of,  356 

in  peritonitis,  355 

treatment  of,  358 
Asepsis,  effects  of,  120 

of  cord,  125 
Asphyxia  cyanotica,  113 

intra-uterine,  113 

of  newborn,  108,  112,  114,  391 

from  lesion  of  nervous  system, 
114 

pallida,  113 
Aspiration  of  cysts,  389 
Aspirin,  reaction  of,  529 
Assimilation,  lost  power  of,  208 
Asthma,  439 

antitoxin  in,  680 

bronchial,  439 

catarrhal,  440 

causes  of,  440 

hay,  440 

paroxysms  of,  440,  441 

thymic,  500,  506 

treatment  of,  442 
Asylum  care  of  infants,  50 
Ataxia,  herecUtary,  804 
cerebellar,  804 
Atelectasis,  115 

acquired,  443 

congenital,  443 

diagnosis  of,  110 

treatment  of,  116 
Athetoid  movements,  106,  107 
Atony  of  intestines,  329 

of  stomach  wall,  299,  301 
Atresia  of  bile  ducts,  99 

of  bowel,  93,  95 

of  vagina,  103 
Atrophy,  muscular,  795 

of  brain,  105 

clinical  picture  of,  208 

of  thymus  gland,  35 

yellow,  of  hver,  376 
Auricular  septum,  451 
Auscultation,  48 

in  bronchopneumonia,  426 

in  children,  456 

in  lobar  pneumonia,  416 
Autodrainage  of  brain,  78 
Auto-inoculation,  591,  598,  713 
Auto-intoxication,  intestinal,  322 


B 


Babies,  handling  of,  116 

Babinski  reflex,   43,   48,   770,   773,   779, 

782,  797,  806,  816,  822,  825,  827 
Bacilli,  growth  of,  188 
Bacillus  acidophilus,  332 

cause  of  cholera  infantum,  293 

coli,  cause  of  pyelitis,  563 

diphtherise,  656 

diphtheroid,  485 

dysentery,  279 

gas,  279 

in  blood  stream,  703 

in  stomatitis,  256 

influenza,  423,  701,  705,  813 

Ivlebs-Loeffier,  392,  677 

lactic  acid,  174 

lactis  aerogenes,  333 

of  Flexner,  279 

of  FriedlJinder,  423 

of  pertussis,  688,  691 

of  Shiga,  279,  288 

of  Shiga-Kruse,  289 

of  tetanus,  133 

pseudodiphtheria,  276 

pyocyaneus,  279 

tuberculosis,  717 

typhosus,  617 

water-borne,  143 
Backwardness,  829,  832 
Bacteria,  air-borne,  121 

anaerobic,  442 

cause  of  appendicitis,  336,  337 
of  endocarditis,  457 
of  joint  disease,  522 
of  meningitis,  810 
'  of  osteomyelitis,  517 

cultures  of,  670 

in  cerebrospinal  fluid,  76 

in  cow's  milk,  141,  142,  143 

in  feces,  195 

in  healthy  membranes,  392,  400 

in  kidneys,  541 

in  otitis  media,  608 

in  spinal  fluid,  778,  817,  823 

in  stomach,  188 

in  throat,  686 

in  tympanic  cavity,  608 

intestinal,  332 

lactic  acid,  143 

pathogenic,  147 

putrefactive,  143,  146,  196 

pyogenic,  524 

spore-bearing,  144 
Balance,  disturbance  of,  205 
Balanitis,  572,  582 
Baldness,  233,  599 
Banti's   disease,  483.    See   also   Splenic 

Anemia. 
Barium  meal,  305 
Barley-water,  149,  239,  284 
Basophiles,  473,  479 
Bath,  alkaline,  371 

daily,  320 

hot,  in  diarrhea,  286 


864 


INDEX 


Bath,  hot,  in  pneumonia,  429 
mustard,  413 

in  measles,  652 

in  typhoid  fever,  628 

infection  by,  617 

temperature  of,  22 
Bathing  of  children,  586 

of  newborn,  21,  40 
Bednar's  aphthae,  250,  257 
Beds,  separate,  58'4 
Bed-sores,  291,  713,  814 
Bed-wetting,  534,  536 
Beef,  inspection  of,  343 

juice,  177,  183,  241,  768 
Behring's  antitoxin,  677,  679 
Belladonna  plaster,  696 
Belt  for  movable  kidney,  563 

for  whooping-cough,  695 
Berries,  cause  of  urticaria,  589 
Bezold's  mastoiditis,  615 
Bier's  hyperemia,  497,  616 

suction  apparatus,  118 
Bile,  composition  of,  369 

ducts,  catarrhal  inflammation  of,  377 
obliteration  of,  99,  119,  375 
obstruction  of,  369,  376 
stenosis  of,  376 

excessive  formation  of,  118 

free  drainage  of,  376 

in  newborn,  20 

pigment,  100,  370,  374 

salts,  192 
Bilious  attacks,  380 
Bilirubin  crystals,  119 
Binder,  knitted,  use  of,  23 
Birth  injurj',  41,  87,  108,  112,  130,  824 

palsies,  106,  108,  792 

premature,  824 

rate  and  infant  mortahty,  51 
reduction  of,  58 

teeth,  220 

weight,  32,  119 
Bismuth  for  enterocolitis,  289 

injections,  95 

meal,  95 
Black  stools,  273 
Bladder,  atom-  of,  535 

blood-clots  in,  568 

calculi  in,  537,  569 

control  of,  26 

diseases  of,  563 

distention  of,  533,  569 

exstrophy  of,  96 

hemorrhage  from,  527 

infection,  564 

inflammation  of,  567 

irrigation  of,  568 

irritability  of,  82,  535,  537 

of  newborn,  20 

puncture  of,  384 

rehef  of,  29 

spasm  of,  568,  569 
Bleeder's  disease,  487 
Bleeding,  gastric,  fatal,  316 

rectal,  366 
Blindness,  817 


Blood,  alteration  in,  371 

bodies  in,  during  pregnane}',  117 

casts,  526 

cells,  white,  in  leukerhia,  479 

circulation  of,  445 
in  newborn,  38 

coagulation  of,  129,  487 

count  in  typhoid,  623 

culture  in  hemophilia,  127 
in  sepsis,  123 
in  typhoid,  623 

diseases  of,  472 

dust,  475 

fetal,  38 

human,  injection  of,  316 

in  anemia,  476 

in  childhood,  472 

in  chlorosis,  477 

in  diphtheria,  668 

in  infancy,  374,  472 

in  leukemia,  480 

in  malaria,  733 

in  pernicious  anemia,  478 

in  pneumonia,  418 

in  stools,  211,  273 

in  syphilis,  744 

in  iirine,  526 

lettmg,  114,  611 

leukocytes  in,  473 

of  newborn,  19 

oozing  of,  488 

oxj'genation  of,  38,  665 

parasite,  732 

physical  properties  of,  472 

picture  in  atrophy  of  liver,  377 

platelets,  475 

reaction  of,  472 

red  cells  in,  472 

serum,  human,  127,  314,  489 
in  poliomyelitis,  786 

specific  gravity  of,  472 

suppl}',  maternal,  739 

tubercle  bacilli  in,  721 

whole,  injections  of,  128 
Blood-pressure,  445,  447,  470 

after  birth,  125 

high,  29 

of  nephritis,  542 
Bloodvessels,  abnormal,  451 

transposition  of,  452,  454 

walls,  in  scurvj',  765 
Blue  babies,  451 
Bodily  protective  power,  720 
Body  fluid  in  cholera  infantum,  293 
reduction  of,  326 

hair,  excessive,  514 

weight,  33,  445 
Boils,  592 
Bone  abscess,  517 

absorption  of,  522 

exuberant  formation  of,  522 

injur}-,  517 

dm-ing  labor,  112 

marrow  in  anemia,  478 
in  leukemia,  480 
red,  extract  of,  483 


INDEX 


865 


Bones,  deformity  of,  138 
diseases  of,  517 
flat,  changes  in,  229,  231 
in  septic  infection,  123 
syphilis  of,  519 
tuberculosis  of,  518,  520 
Bordet-Gengou  bacillus,  688,  691 
Bosses,  cranial,  235,  522 

in  rickets,  229 
Bothriocephalus  latus,  342 
Bottle  feeding,  151 
Bottle-fed  balDies,  cholera  in,  293 
colic  in,  312 
constipation  in,  327 
gastritis  in,  295 
mastoiditis  in,  616 
mortality  among,  62,  162 
pertussis  in,  691 
pylorospasm  in,  301 
rickets  in,  241 
scurvy  in,  764 
stools  of,  273 
summer  diarrhea  in,  283. 
thrush  in,  254 
Bottles,  nursing,  care  of,  183,  223,  283 
Bovine  tuberculosis,  718 

vaccine  virus,  715 
Bowels,  atresia  of,  94 
in  typhoid,  621 
malposition  of,  95 
obstruction  of,  323,  360 
regular  habits  of,  93 
twisting  of,  335 
ulceration  of,  292 
Bow-legs,  24,  237,  244 
Boys,  breasts  of,  859 

development  of,  853,  855 
masturbation  in,  860 
puberty  in,  851 
vocal  cords  of,  854 
Brachial  plexus,  plan  of,  110 
Bradycardia,  447 
Bradylaha,  827 
Brain,  abscess  of,  610,  615 
absence  of,  80,  81 
autodrainage  of,  78 
capacity,  71 

cells,  transmission  of,  70 
congenital  maldevelopment  of,  75 
demand  for  blood  in,  819 
diseases  of,  824 
development  of,  arrested,  105 

in  infant,  28 
herniae  of,  72 
malformations  of,  72 
miliary  tubercles  in,  728 
syphilitic  changes  in,  743 
tuberculosis  of,  721 
tumors,  80,  813 
weight  of,  42,  769 
Branchial  clefts,  86 
Bread,  secretion  produced  by,  187 
Breast  feeding,  158 

advantages  of,  161 
frequency  of,  160 
impossibility  of,  161 
55 


Breast  feeding  in  pylorospasm,  303 
regularity  in,  160 
supplemented  by  bottle,  162 
milk,  amount  of,  164 
analysis  of,  163 
average  composition  of,  165 
cause  of  indigestion,  163 
diminution  of,  162 
effect  of  alcohol  upon,  59 
fat  content  of,  268 
retention  of,  117,  164 
standard,  162 
Breast-fed  babies,  mortality  among,  62 
Breasts  at  puberty,  859 

bacterial  infection  of,  118 
caked,  283 
enlargement  of,  854 
inflammation  of,  161 
of  infants,  milk  in,  117,  118 
Breath,  foul,  250,  660 

in  pyorrhea,  260 
gangrenous,  443 
pear-like  odor  of,  265 
urinous,  543 
Breathing,  bronchial,  416,  420,  435 
Cheyne-Stokes,  822 
exercises,  438,  442 
impaired,  397 
in  sexes,  853 
Breathlessness,  457 
Breck  feeder,  83 
Breech  presentations,  birth  injuries  in, 

108,  112 
Bromide  rash,  605 
Bronchi,  diseases  of,  408 
Bronchial  glands,  suppuration  of,  726 

tubes,  narrowing  of,  440 
Bronchitis,  acute,  408 

auscultation  in,  410 
etiology  of,  409 
expectoration  in,  410 
mild  form  of,  410 
pathology  of,  409 
percussion  in,  410 
prophylaxis  in,  411 
respiration  in,    411 
severe  type  of,  411 
symptoms  of,  410 
treatment  of,  412,  413 
asthmatic,  440,  441 
differentiated  from  pneumonia,  419 
in  pertussis,  689 
in  rickets,  232 
Bronchophony,  416 
Bronchopneumonia,  423 

accompanying  enterocolitis,  288 

as  a  house  disease,  423 

bilateral,  424 

complications  of,  427 

convalescence  in,  430 

cyanosis  in,  430 

diagnosis  of,  426 

differentiation  of,  424 

due  to  diphtheria  bacillus,  679 

in  diphtheria,  666 

in  dysentery,  290 


866 


INDEX 


Bronchopneumonia  in  infants,  423,  427 

in  measles,  644,  649 

in  pertussis,  691 

masking  whooping-cough,  427 

mortahty  from,  63 

prophylaxis  of,  427 

relapse  in,  425 

sick-room  in,  428 

stimulation  in,  430 

symptoms  of,  424 

treatment  of,  428 

tuberculous,  722,  724 
Bronchus,  foreign  body  in,  443 

occlusion  of,  416 
Broths  in  diet,  289 

meat,  for  infants,  177 
Brown-Sequard  syndrome,  780,  806 
Bruidzinski's  sign,  774,  816,  821 
Bruit,  447.     See  also  Murmurs. 

aortic,  458 

de  galop,  635 

in  mitral  stenosis,  463 

right-sided,  450 
Brunner's  glands,  19,  191,  192 
Buhl's  disease,  121,  128,  130 
Bulbar  palsy,  789 
Bulgarian  bacillus,  175 
Burial  clubs,  58 
Buttermilk,  174,  175,  320 
Buttock,  eczema  of,  200,  281,  318 

pus  in,  368  , 


Cachexia,  fatty  liver  in,  385 

in  kidney  tumor,  556 

in  lymphatic  anemia,  485 
Calcification  in  rickets,  231 
Calcium  phosphate,  158 

salts,  189,  229 
Calcuh,  urethral,  532,  569 

vesical,  567 
Calmette  test,  731 
Calomel  fumigation,  686 

in  acetonuria,  529 

in  gastric  indigestion,  275 

purgation,  329,  372,  677 
Caloric  feeding,  179 
Calorie  production  in  infancy,  40 
Calories,  infant  requirement  of,  160 

in  food  elements,  155 
Camp  life,  215 

Canal  of  Nuck,  hydrocele  of,  98 
Cancrum  oris,  257 
Cane  sugar,  269,  270 

alcoholic  fermentation  in,  179 
Caput  succedaneum,  78 
Carbohydrate  indigestion,  157,  269,  319 
Carbohydrates,  cause  of  fat,  386 

excessive  use  of,  317,  530 

in  flours,  157 

in  infant's  food,  200 

in  mother's  milk,  156 

value  of,  196 

variety  of,  178 
Carbolic  acid,  use  of,  592 


Carbon  dioxide  in  blood  of  newborn,  116 
Cardia,  ulceration  of,  315 
Cardiac  depression,  653 

dulness,  areas  of,  49,  455,  466 
increase  in,  464 
Cardiorespiratory  centre,  772 
Cardiospasm,  congenital,  88 
Carditis,  469 
Caries,  dental,  222,  225,  250 

vertebral,  781 
Carotids,  throbbing  of,  463 
Carpopedal  spasm,  404 
Carriers  of  disease,   121,  629,  658,  663, 

793,  815,  818 
Cartilage,  production  of,  229 

ossification  of,  138 
Cascara  sagrada,  329,  333 
Caseation,  tuberculous,  497 
Casein,  cause  of  indigestion,  272 

clotting  of,  154 

curds,  145,  201 

in  stools,  211,  272 

of  milk,  154,  189 

precipitation  of,  189 
Castile  soap,  cones  of,  328 
Castor  oO  in  dysentery,  291 

purgation,  253,  255,  271 
Castration,  574 

effect  of,  on  thymus,  502 
Casts,  hyaUn,  385 

membranous,  660,  665 

of  larynx  and  trachea,  687 

urinary,  669 
Catarrh  of  air  passages,  411,  428 

postnasal,  438 
Catarrhal  affections,  818 

fever,  701.     See  also  Influenza. 
Cathartics,  hydragogue,  358 

saUne,  330 
Cathelin's  treatment,  538 
Catheter,  feeding  by,  248 

for  infant  enema,  148 

passage  of,  533,  569,  579 
Cattle,  tuberculosis  in,  718 
Cauda  equina,  tumor  in,  807 
Cauterization,  90,  581,  612 
Cautery,  actual,  in  noma,  259 

in  myelitis,  784 
Cavities,  dental,  225 

of  heart,  abnormal,  452 
Cavity  in  spinal  cord,  803 

tuberculous,  442,  722 
Cecum,  worms  in,  344,  345,  348 
Cellulitis,  496 

Cellulose,  utilization  of,  157 
Cephalhematoma,  78,  80 

double,  79 

symptoms  of,  80 

treatment  of,  80 
Cephalocele,  72 
Cereal  diluents,  149 
Cereals  in  diet,  183,  201,  328 
Cerebellum,  development  of,  43 
Cerebral  irritation,  638 

puncture,  778 

softening,  501 


INDEX 


867 


Cerebral  tumor,  symptoms  of,  516 
Cerebrospinal  fluid,  contents  of,  76 

examination  of,  809,  811,  812, 

823 
findings  in,  817 
meningitis,  814 
acute,  817 

forms  of,  aberrant,  816,  817 
malignant,  816,  817 
postbasic,  816,  817 
joints  in,  754 

symptoms  of,  nervous,  816 
Cereo  gruel  flour,  156 
Cervical  adenitis,  496 

tuberculous,  718,  727 
glands,  enlarged,  495 

inflammation  of,  495 
removal  of,  487 
Cesarean  section,  79,  140 
Cestodes,  341 

Chiamber,  child's  use  of, '330 
Chancre,  738,  739 
Characters,  acquired,  69 
individual,  852 
inherited,  71 
transmission  of,  68,  69 
Char  cot-Ley  den  crystals,  441 
Chest,  capacity  of,  853 

deformity  of,  233,  235,  398 
systolic  retraction  of,  468,  469 
wall,  incision  of,  380 
Cheyne-Stokes  breathing,  783 
Chicken-breast,  235 
Chicken-pox,  639.     See  also  Varicella. 
Child-crowing,  404,  406 
Child  labor,  29,  34 
ChiUing  of  body,  137,  313 
Chloride  retention,  545 
Chloroform  in  reducing  prolapse,  364 
Chlorosis,  476 

blood  picture  in,  477 
etiology  of,  477 
from  auto-intoxication,  477 
symptoms  of,  477 
treatment  of,  482 
Cholelithiasis,  378 
Cholera,  Asiatic,  294 
infantum,  292 

bacilli  in,  293 

degenerative  changes  in,  293 
diagnosis  of,  294 
etiology  of,  292 
pathology  of,  293 
stimulation  in,  295 
stools  in,  293 
symptoms  of,  293 
Cholagogues,  279 

Chondrodystrophy,  138.    See  also  Achon- 
droplasia. 
Chorea,  841 

at  puberty,  857 
cause  of  pericarditis,  465 
diet  in,  845,  846 
electric,  841 
epidemic,  844 
forms  of,  841    • 


Chorea,  imitation  in,  841 

in  rheumatism,  747,  752 

mental  state  in,  844 

minor,  841 

movements  in,  772,  843 

relapses  in,  844,  846 

rheumatic,  846 

sex  in,  842 

simulated  by  exophthalmos,  509 

symptoms  of,  842 

treatment  of,  845 
Choroid,  tubercles  in,  725 
Choroiditis,  both  eyes,  697 
Chvostek's  sign,_  774,  848 
Chyme,  composition  of,  193 
Circulation,  fetal,  18,  37,  445 

hemoglobin  in,  527 

in  bronchopneumonia,  425 

postnatal,  18 

pulmonary,  establishment  of,  125 

unstable,  507 
Circulatory  system  at  puberty,  854,  857 
Circumcision  at  puberty,  859 

diphtheritic  infection  in,  667 

dysuria  following,  532 

for  balanitis,  572 

for  phimosis,  571 
Cirrhosis,  atrophic,  381 

cardiotubercular,  381 

hypertrophic,  382 

of  liver,  381,  383 

syphilitic,  383 
.City  life  in  relation  to  infant  mortality, 
53 

summer  diarrhea  in,  331 
Cleanliness  of  mouth,  251 
Cleft  palate,  82,  84,  85 
Clefts,  branchial,  68 
Climate,  change  of,  in  influenza,  707 
in  tuberculosis,  731 

in  asthma,  442 

in  nephritis,  546,  550 
Clonus,  ankle,  773 

patellar,  773 
Clot,  cerebral,  operation  for,  108 
Clothing  of  infant,  22,  23 
Club-fingers,  449 
Club-foot,  798 

in  myelocytocele,  101 
Coagulose,  314 
Cod-liver  oil  in  rickets,  241,  242 

in  tuberculosis,  732 
Coffee  by  rectum,  278 
Cold  air  treatment,  214,  216 

applications,  in  prolapse,  364 
to  heart,  509 

cause  of  nephritis,  542 

in  head,  391 

severe,  exposure  to,  818 
CoUc,  312 

differentiation  of,  313,  339 

from  indigestion,  200,  270,  319 

gall-stone,  311 

habitual,  272,  314 

renal,  556 

symptoms  of,  204 


868 


INDEX 


Colitis,  amebic,  291 

catarrhal,  766 

mucous,  333 

ulcerative,  362 
CoUe's  law,  740 
Colon,  absorption  in,  194 

bacillus  in  urine,  537 

dilatation  of,  congenital,  92,  93 

distention  of,  300 

flushing  of,  533,  546,  845 

irrigation  of,  286,  291 

location  of,  557 

worms  in,  345,  348 
Color  index  in  newborn,  19 
Colostrum  corpuscles,  31,  159,  161 
Compensation  in  children,  464 

ruptured,  460,  462 

secondary,  504 
Complement-fixation  test,  691 
Conception  at  early  age,  851 
Concretions,  fecal,  336 
Condensed  milk,  150,  317 

in  scurvy,  764 
Congestion,  pulmonary,  321,  429 

renal,  539 

venous,  137 
Conjunctiva,  icterus  of,  120 

pearly,  475 
Conjunctivitis,  224 

in  measles,  647 

in  varioloid,  711 
Consanguinity,  68,  510,  829 
Constipation,  cause  of  hemorrhoids,  365 
of  vomiting,  265 

chronic,  326 

due  to  atresia,  94 
to  diet,  202,  327 
to  dilatation  of  colon,  92 

etiology  of,  326 

from  fat  indigestion,  200 

from  intoxication,  282 

hereditary,  326 

in  intussusception,  324 

symptoms  of,  326 

treatment  of,  329 
Contractures,  790 

in  muscular  paralysis,  800 
Convulsions,  causes  of,  772 

control  of,  106 

due  to  rickets,  233 

from  atresia  of  bile  ducts,  101 

in  catarrhal  gastritis,  276,  278 

in  cerebral  palsy,  827 

in  diphtheria,  659 

in  idiocy,  830 

in  laryngeal  spasm,  404 

in  measles,  650 

in  natal  paralysis,  107 

in  pneumonia,  420,  422 

infantile,  698 

treatment  of,  243 

uremic,  105,  546,  637 
Cord,  encysted  hydrocele  of,  98 

spinal,  malformations  of,  72,  778 

umbilical,  asepsis  of,  121 
bleeding  from,  126 


Cord,  umbilical,  desiccation  of,  124 

hernia  of,  90 
Corpus  callosum,  puncture  of,  78 
Coryza  acquired  by  contact,  427 

diphtheritic,  392 
Cough,  expiratory,  689 
in  asthma,  441 
in  bronchopneumonia,  425 
in  chronic  gastritis,  296 
in  measles,  646,  652 
in  mitral  disease,  438  , 

in  pertussis,  689,  690 
nervous,  439 
paroxysmal,  406 
persistent  unproductive,  261 
reflex,  438 
Coullet  dining-rooms,  57 
Councilman's  protozoon,  708 
Counter-irritation,  412,  429,  539 
Country  air,  215 

Cow-pox,  713.    See  also  Vaccinia. 
Cow's  milk  as  infant  food,  152 
bacteria  in,  141 
care  of,  141 
coagula  of,  45 
compared    with,    breast    milk, 

167,  168 
composition  of,  141 
diluents  of,  149 
milk  sugar  in,  156,  168 
modification  of,  167,  303 
production  of,  141 
protein  in,  154 
raw,  146 
Coxa  vara,  237,  238 
Craniotabes,  521,  522 
as  a  symptom,  48 
in  rickets,  234,  237 
Cranial  puncture,  778,  810 
Cranium,  fluid  within,  75 

thin  spots  in,  521 
Cream,  bacteria  in,  142 

fat  content  of,  169,  172,  181 
gravity,  169 
in  milk,  173 

mixtures,  168,  172 
intolerance  to,  304 
whey  mixtures,  271 
Creeping,  42,  244 
Crib  for  infant,  24 

tent,  686  _ 

Creosote  for  bronchitis,  412 
Crepitation,  416 
Cretinism,  510,  829 
diagnosis  of,  512 
differentiated  from  rickets,  238 
endemic,  510 
hereditary,  510 
pathology  of,  510 
prognosis  of,  513 
simulated,  349,  835 
symptoms  of,  510 
treatment  of,  513 
Cretins,  appearance  of,  510 
mentality  of,  511 
training  of,  511 


INDEX 


869 


Crises,  abdominal,  492,  515 
Croup,  catarrhal,  671 

false,  400 

naembranous,  665,  671 

spasmodic,  400 

tent,  412,  429 
Crowing,  laryngeal,  404,  406 
Cry,  hydrocephalic,  821 

of  child,  significance  of,  49 
Cryptorchidism,  97 
Ciystals,  calcium  oxalate,  528 

uric  acid,  528,  554 
Culture  tubes,  670 
Cultures,  diphtheria,  657,  663,  671,  673 

from  urine,  531 

negative,  674,  687 
Cupping,  dry,  413,  421 
Curdling  in  stomach,  188 

of  milk,  189 
Curds,  casein,  201 

in  stools,  194 

of  protein  indigestion,  201 
Curette,  use  of,  399 
Curschmann's  spirals,  441 
Cyanosis  as  a  symptom,  47 

in  bronchopneumonia,  424 

in  pulmonary  stenosis,  454 

in  newborn,  451 

of  atelectasis,  115 

of  lips,  fingers,  and  toes,  462 

treatment  of,  471 
Cyclic  vomiting,  264 
Cyst,  abdominal,  357 

congenital,  105 

echinococcic,  369 

hydatid,  389 

of  kidney,  558 

of  liver,  389 

of  neck,  87 

of  umbilicus,  89 

parasitic,  495 

retention,  389,  558 

rupture  of,  389 

tapeworm,  342 

unilocular,  389 
Cystic  duct.    See  Bile  Ducts. 

kidney,  congenital,  560 
Cystitis,  567 

after  typhoid,  567 

chronic,  567 

etiology  of,  567 

in  influenza,  705 

treatment  of,  567 

with  pyelitis,  565 
Cytology  of  spinal  fluid,  817 


D 


Dactylitis,  syphflitic,  236,  520,  744 

tuberculous,  520 
Dairy  farms,  model,  142,  144 
Dampness,  748,  759 
Deaf-mutism,  68,  86,  635 
Deafness,  causes  of,  68,  817 

in  cretins,  511 


Deafness  in  diphtheria,  666 

in  idiocy,  831 

syphihtic,  743,  745 
Decomposition,  alimentary,  207 
Defecation,  330 

habits  of,  536 

painful,  367 
Defects,  physical,  830 
Deformity,  ataxic,  805 

bony,  229,  519 

from  cicatrix,  742 

in  rickets,  240,  244 

of  chest,  causes  of,  37 

of  neck,  87 
Degeneracy  in  type,  71 
Degenerates,  moral,  832 
Degeneration,  reaction  of,  774 
Delirium  in  cholera  infantum,  294 

in  diphtheria,  667 

in  meningitis,  610 
Dental  sacs,  217,  219 
Dentin,  formation  of,  219 
Dentition,  217,  219 

a  natural  process,  50,  218 

cause  of  disease,  217 

conditions  due  to,  223 

complete,  diet  after,  183 

delayed,  221,  835 

fever,  432 

in  rickets,  221,  233 

multiple,  222 

normal,  185 

premature,  220 
Dermatitis  exfoliativa  neonatorum,  602 

gangrenous,  601 

medicamentosa,  605 
Desquamation  in  scarlet  fever,  633 
Development  affected  by  temperature, 
855 

before  puberty,  851 

cerebral,  arrested,  832 

defective,  450,  557,  562,  829 

mental,  829,  852 

muscular,  853 

of  body,  830,  851 

of  child,  28 

of  fetus,  450 

of  man,  68 

of  senses,  771 

physiological,  770 

precocious,  of  genitalia,  581 

psychological,  771 
Dextrin-maltose,  179,  270,  271 
Dextrocardia,  454 
Diabetes,  cause  of  enuresis,  536 

insipidus,  534 

mellitus,  390,  530,  534 
Diabetics,  acetonuria  in,  529 
Diapers,  23,  27,  284 

disease  transmitted  by,  577 
Diaphragm,  tugging  of,  672 
Diarrhea,  331 

causes  of,  331 

classiflcation  of,  332 

during  teething,  224 

epidemic,  53,  60 


870 


INDEX 


Diarrhea,  fatty,  197 
in  measles,  651 
infantile,  60,  698 
infectious,  279 
mortality  from,  66,  61,  698 
summer,  279,  280 
treatment  of,  332 
Diastase  in  infant  feeding,  149 
Diathesis,  lymphatic,  495 
rheumatic,  747,  752 
tuberculous,  852 
Diazo-reaction,  Ehrlich's,  623 
Diet  after  weaning,  183 
at  given  ages,  183 
in  bronchitis,  412 
in  cirrhosis,  383 
in  diarrhea,  332 
in  endocarditis,  461 
in  gastritis,  278 
in  ileocolitis,  322 
in  mucous  colitis,  334 
in  myocarditis,  471 
in  nephritis,  545 
in  pneumonia,  420 
in  pylorospasm,  303 
in  rickets,  241 
lack  of  residue  in,  327 
necessity  of  fat  in,  199 

proteins  in,  202 
semisolid,  278 
soft,  625 
vegetable,  191 
Digestion,  effect  of,  on  spleen,  493 
in  hot  weather,  279 
in  newborn,  19 
normal,  184 
Digestive  apparatus,  functions  of,  186 

system,  strain  upon,  246 
Dilatation  of  colon,  92,  93 

of  stomach,  299 
Diluents,  149,  150 
Diphtheria,  656 

after  measles,  649 
antisepsis  in,  675 

antitoxin,  128,  402,  541,  638,  651, 
665,  672 

administration  of,  681 

death  following,  680 

dose  of,  678,  681 

in  nephritis,  545 

in  pneumonia,  679 

production  of,  677 

repeated  injections  of,  681 

value  of,  679 
bacillus,  657 

in  nose,  662,  663 

virulence  of,  658,  661 
bacteriology  in,  670 
carriers,  658,  663 
cause  of  neuritis,  836 
complications  of,  541,  668 
conjunctival,  667 
contagion  of,  656 
cultures,  657,  666,  670 

negative,  663 
diagnosis  of,  670 


Diphtheria,  diet  in,  676 
differentiation  of,  671 
discharge  in,  392 

nasal,  660,  676,  678 
disinfection  in,  673 
epidemic,  ,672 
etiology  of,  656 
false,  686 

feeding  in,  after  intubation,  683 
fever  in,  667 

followed  by  myocarditis,  470 
gastro-enteritis  in,  670 
hemorrhage  in,  nasal,  670 
immunity  to,  674,  677 
in  hospitals,  regulations  concerning, 

664 
incubation  period  in,  658 
irrigations  in,  664 
isolation  in,  661 
kidneys  in,  668 
laryngeal,  665,  685 

suffocation  in,  666 
laryngotracheal,  669 
leukocytosis  in,  474 
lungs  in,  669 
membrane  formation  in,  660,  662, 

672,  685 
morbid  anatomy  of,  668 
mortality  from,  672,  698 

effects  of  antitoxin  on,  679 
nasal,  660 

antitoxin  in,  665 

irrigation  in,  664 
nasopharyngeal,  673 
nervous  disturbances  in,  667 
odor  in,  659 
operation  in,  682 
paralysis  in,  669,  678 
pharyngeal,  658 
prognosis  in,  672 
prophylaxis  in,  673 
pulse  rate  in,  667 
relapses  in,  680 
reporting  of,  661 
return  cases  of,  663 
scarlatinal,  686 
septic,  667 
sequelae  of,  668 
severe  types  of,  660,  672,  678 
simulated  by  pseudodiphtheria,  686 
spread  by  milk,  143 
stimulation  in,  677 
stools  in,  660 
streptococcus,  686 
sudden  death  in,  669 
susceptibility  to,  658 
swallowing  in,  684 
symptoms  of,  659 
tiaroat  in,  675 
thymic  death  in,  507 
transmission  of,  658 
treatment  of,  after  intubation,  683 

by  drugs,  676 

by  irrigations,  664,  676 

by  serum.  677 

constitutional,  676 


INDEX 


871 


Diphtheria,  treatment  of,  hygienic,  675 
in  Widener  School,  681 
local,  675 

urine  in,  660 
Diphtheritic  paralysis,  836 
Diplegia,  cerebral,  825,  826 
Diplococcus  found  in  chorea,  842 

Gram-negative,  815 

intracellularis  meningitidis,  814 

of  Frankel,  702 

pneumoniae,  414 
Dirt-eaters,  349 

Disfigurement  from  smallpox,  712 
Disinfection  after  measles,  652 

in  diphtheria,  673,  675 

in  scarlet  fever,  636 

in  typhoid,  625 

in  varioloid,  712 

of  nasal  passages,  393 
Diuretics,  alkaUne,  529 

for  ascites,  383 
Diverticulum,  Meckel's,  etiology  of,  89 
Dog  bite,  502 
Douche,  cold  water,  364 

vaginal,  579 
Drainage  of  brain,  78 
Drooling,  185,  223 
Dropsy  in  anemia,  478 

in  nephritis,  550 
Drowsiness  in  meningitis,  821 
Drug  rashes,  634 
Drugs,  cause  of  purpura,  489 
Dubini's  disease,  841 
Ductus  arteriosus,  19,  38 
patent,  450,  453 

omphalomesentericus,  88 
Dulness,  splenic,  493 
Duodenum,  inflammation  of,  279 
Dwarfs,  138,  512,  745 
Dwelling,  maximum  temperature  in,  41 

size  of,  215 
Dysarthria,  827 
Dysentery,  289 

amebic,  289,  291 

bacillary,  289,  291 

cause  of  prolapse,  363 

complications  of,  291 

diet  in,  292 

hygiene  of,  292 

opium  in,  292 

resembling  enterocolitis,  287 

treatment  of,  291 

ulcerative,  290 
Dyspepsia,  206 

at  puberty,  858 

in  heart  disease,  462 
Dyspnea  after  intubation,  683,  684 

due  to  thymus,  505 

in  bronchopneumonia,  425 

in  diphtheria,  665 

laryngeal,  401,  406 

reUef  of,  444 
Dystrophy,  muscular,  798 

f  icies-scapulohumeral,  798,  801 
J  seudohypertrophic,  798 
S'japulohumeral,  798,  801 


Dysuria,  532 

from  calculi,  532 
treatment  of,  532 


E 


Ear,  bone  necrosis  in,  613 

diseases  of,  607 

discharge  from,  611,  613 

drum,  perforation  of,  609,  613 

puncture  of,  611,  614,  653,  696 

examination  of,  611,  613 

foreign  bodies  in,  607 

furuncles  in,  610 

inflammation  of,  225 

middle,  disease  of,  398 

noises  in,  609,  610 

pus  in,  609 

syringing  of,  607,  612 

ulceration  in,  613 
Eating  between  meals,  320 

hurried,  274 
Eberth's  bacillus,  617 
Ecchymoses  in  atrophy  of  liver,  378 

in  purpura,  491 

in  scurvy,  766 
Eclampsia,  503,  813 

after  serum  therapy,  503 

infantile,  225 
Eczema,  etiology  of,  586 

facial,  204 

from  pediculi,  603 

moist,  594 

of  anus,  321 

of  genitalia,  571 

of  hps,  247 

of  scalp,  587 

pustular,  587 

subacute,  588 

treatment  of,  587 

vesicular,  586 
Edebohls'  operation,  551 
Edema  due  to  anemia,  475 

to  potassium  iodide,  402 

in  heart  disease,  466 

in  nephritis,  543 

inflammatory,  403 

of  legs,  382 

pulmonary,  507 
Effusion,  abdominal,  469 

pericardial,  467 

pleural,  431,  469,  727 
Eiweissmilch,  173,  271,  284,  320 
Electrical  reactions,  840 

stimulation  in  infancy,  41 
Electricity  for  constipation,  329 

in  infantile  paralysis,  794 

in  myotonia  congenita,  802 

in  removal  of  moles,  601 
Emasculation,  854 
Embryo,  effects  of  poisons  on,  450 
Embryonal  tissue  a  site  of  tumor,  556 
Emetics,  685 
Emphysema,  444 

compensatory,  444 


872 


INDEX 


Emphysema  due  to  asthma,  442 
to  foreign  body,  408 

interstitial,  444 

subcutaneous,  444 
Empyema,  430.    See  also  Pleurisy. 

bilateral,  438 

leukocytosis  in,  474 

operation  for,  436 

prognosis  of,  436 

sacculated,  435 
Enamel,  formation  of,  221 
Enanthem  of  rubella,  655 
Encephalitis  a  cause  of  palsy,  825 
Encephalocele,  74 
Encephalomyelitis,  779 
Encephalopoliomyelitis,  828 
Endocarditis,  650 

acute,  457 

diagnosis  in,  460 
treatment  of,  460,  461 

chronic,  461 

physical  signs  of,  462 
prophylaxis  of,  464 
pulse  in,  462 
symptoms  of,  462 
treatment  of,  464 

fetal,  450 

from  bacteria,  457 

in  rheumatism,  750 

malignant,  457,  459 

postnatal,  457 

rheumatic,  756 

ulcerative,  460 
Enema  for  colic,  313 

soap,  328 
Enemata,  abuse  of,  328 

nutrient,  148,  266 
Engorgement,  venous,  433 
Enteralgia,  312 
Enteritis  in  bottle-fed  babies,  62 

infantile  mortality  from,  56,  61 

tuberculous,  530 
Enterocolitis,  acute,  287 
etiology  of,  287 
treatment  of,  289 
Enuresis,  534 

after  puberty,  536,  858 

and  fecal  incontinence,  330 

causes  of,  537 

diurnal,  534 

due  to  diabetes,  536 

to  malformations,  535 

from  vulvovaginitis,  578 

inherited  tendency  to,  535 

treatment  of,  538 
Environment  as  factor  in  infant   mor- 
tality, 54 

change  of,  320 

effects  of,  69,  70 
Enzymes  from  intestinal  wall,  192 

proteolytic,  188 
Eosinophilia,  341 

due  to  worms,  341,  343,  347 
Eosinophils,  473,  474,  479 
Epidemic  dysentery,  291 

meningitis,  814 


Epidemic  pemphigus  neonatorum,  601 
Epidemics  in  institutions,  128 

of  diphtheria,  661,  672 

of  measles,  642,  643,  644 

of  pertussis,  695 

of  scarlet  fever,  628 

of  summer  diarrhea,  280 

of  tetany,  847 

of  typhoid,  624 
Epidermis,  maceration  of,  590 
Epididymis,  inflammation  of,  573 

tuberculous,  574 
Epididymitis  in  mumps,  700 
Epilepsy  at  puberty,  857,  858 

in  cerebral  palsy,  826 

Jacksonian,  816,  822 
Epileptics,  urine  of,  529 
Epinephritis,  551 
Epiphysis,  infection  in,  518 
Epiphysitis,  acute,  522 

syphilitic,  519,  746 

tuberculous,  523 
Epispadias,  96,  104 
Epistaxis,  395 

in  cirrhosis,  382 

in  rheumatism,  754 

renal,  526 
Epithelium,  desquamation  of,  288,  290 
Equilibrium  of  body,  799 
Equinovarus,  798 
Erections  in  children,  583 
Erb's  myotonic  reaction,  803 

palsy,  108,  109,  110 

phenomenon,  774,  848 
Eruption,  bullous,  601 

due  to  drugs,  605 

exudative,  595 

papular,  593,  594 

papulopustular,  606 

pustular,  593,  709,  740 

scaly,  587,  594 

"shot-like,"  711 

syphilitic,  743 

urticarial,  713 

vesicular,  591,  593,  601,  639 
Erysipelas    differentiated  from   eczema, 
587 

of  ear,  615 

of  newborn,  131 
Erythema  multiforme,  593 
Erythrocytes  in  the  blood,  472 

maternal,  118 
Esophagitis,  261 

from  acids  or  corrosives,  262 
Esophagus,  congenita]  malformation  of, 
88 

foreign  body  in,  261 

rupture  of  abscess  into,  262 

stricture  of,  262 
Ether  in  reduction  of  hernia,  361 
Eunuchs,  859 
Euquinine,  737 
Eustachian  tube,  blocking  of,  608 

infection  in,  614 
Evolution  in  higher  animals,  70 

processes  of,  851 


INDEX 


873 


Examination,  bacteriological,  670 

clinical,  46 

electrical,  774 

medical,  of  children,  28 

microscopic,  497,  576 

of  ear,  609,  614 

physical,  of  heart,  454 

sensory,  774 
Exercise  for  infant,  24 

in  heart  disease,  465 

unilateral,  857 
Exhaustion  products,  450 
Exophthalmic  goitre,  509 
Expression,  pinched,  456 
Extremities,  atrophy  of,  796 

blue,  296 

deformity  of,  236,  244 

edema  of,  321 

lengthening  of,  852 

lower,  paralysis  of,  669 

spasms  of,  846 

weakness  of,  831 
Exstrophy  of  bladder,  96,  97 
with  epispadias,  104 
Extubation,  684 
Exudate  in  meningitis,  820 
Eye  reaction,  731 

strain,  846 

symptoms  in  palsy.  111 
Eyelid,  descent  of,  509 
Eyes,  bulging,  509 

care  of,  26 

in  measles,  644,  650 

infection  of,  580 

inflammation  of,  817 

puffiness  of,  384 


Face  of  newborn  infant,  17 

pasty,  543 
Facial  expression,  456,  835 

palsy.  111,  837,  839 
Factory  women,  infants  of,  52,  56 
Fainting  attacks,  456 
Familial  jaundice,  373,  374 
Family  disease,  795,  798,  802,  804 

history,  46 

traits,  852,  856 

transmission  of  disease,  487 
Faradic  current,  329 
Faradism  in  Erb's  palsy,  110 
Fat  absorption,  502 

assimilation  of,  292 

cream,  percentages  of,  180 

deposition  of,  155 

diarrhea,  200 

droplets  in  liver,  377,  386 

in  infant's  food,  177 

in  stools,  195,  211 

indigestion,  151,  199,  267 
in  bottle-fed  babies,  267 
stools  in,  274 

injuries,  200 

intolerance  to,  268 


Fat  metabolism,  155 

mixtures  for  constipation,  328 

of  cow's  milk,  205 

percentages,  171 

taking  on  of,  514 
Fats,  155 

digestion  of,  193 

splitting  of,  191 

variety  of,  178 
Fatty  degeneration  of  newborn,  128 

liver,  385 
Faucitis,  diphtheroid,  671 
Fecal  matter,  absorption  of,  322 
Feces,  color  of,  210 

composition  of,  195,  211 

consistency  of,  211 

discharge  of,  at  umbilicus,  89 

examination  of,  209 

form  of,  195 

incontinence  of,  330,  333 

normal,  194,  273 

of  newborn,  273 

reaction  of,  209 
Feeble-mindedness,  828 
Feeding  after  intubation,  683 

after  weaning,  183,  317 

artificial,  206 

by  catheter,  248 

excessive,  205 

improper,  cause  of  indigestion,  274 

of  infants,  141 

percentage,  172 

problem,  203 

regularity  in,  317 
Feedings,  infrequent,  in  summer,  283 
Ferment,  fat-splitting,  45 
Fermentation,  gastro-intestinal,  206 

intestinal,  173,  200,  331 
Fetal  circulation,  37 

conditions,  persistent,  452 
Fetus,  faulty  development  of,  450 

syphilitic,  742,  743 

typhoid  fever  in,  618 
Fever  blister,  596.    See  Herpes  Labiahs. 

causes  of,  41 

in  otitis,  609 

inanition,  204 

obscure,  563 

quotidian,  733 

reduced  by  baths,  626 

rheumatic,  492 
Filix  mas  for  tapeworm,  344 
Fingers,  biting  of,  223 

necrosis  of,  521 
Fish,  cooking  of,  343 
Fish-skin  disease,  589 
Fistula,  anal,  329,  365 

bhnd,  367 

of  neck,  86,  87 

of  urachus,  89 

rectal,  94 
Flashes  of  heat,  855 
Flat-foot,  237 
Flatulence  in  infants,  272 
Flatus  from  indigestion,  318 
Flexner  bacillus,  289 


874 


INDEX 


Flexner's  serum,  707,  817 
Floating  kidney,  562 
Flours,  standardized,  157 
Fluid,  body,  loss  of,  290 

cerebrospinal,  76 
Fluids,  regurgitation  of,  836 
Fomentations,  316 

Fontanelle,  anterior,  closure  of,  34,  235 
palpation  of,  47 

bulging  of,  106,  108,  114 
Fontanelles  as  landmarks,  18 

distention  of,  809 
Food,  amount  of,  45 

anaphjdaxis,  203 

aspiration  of,  837 

assimilation  of,  246 

bacteria  in,  202 

bolting  of,  397 

composition  of,  204 

elements,  153 

excess  of  fat  in,  200 

fried,  320 

heated,  764 

in  hot  weather,  283 

indigestible,  274 

injuries,  199,  271 

iron  requirement  in,  158 

passage  of,  from  stomach,  45 

patent,  for  infants,  176,  227,  240, 
317,  320 

sadt  in,  550 

sohd,  for  infant,  183 

sterilized,  action  of,  196 
Foot-and-mouth  disease,  252 
Foot-drop,  797,  838,  839 

tuberculosis  of,  518 
Foramen  ovale,  18 

closure  of,  39 

passage  of  blood  through,  38 
patent,  453 
Forceps  deUverj',  108 

cause  of  palsy,  111 
Foreign  bodies,  aspiration  of,  407,  443 
in  ear,  607 
in  nose,  393 
Foundlings,  farming  out  of,  67 

institutions  for,  404 

measles  among,  644 

mortahty  among,  64 
Fountain  syringe,  use  of,  664 
Fowler's  solution  in  chorea,  845 

neuritis  from,  839 
Fractures,  compound,  517 

during  deUvery,  109,  112 

green-stick,  236 

in  rickets,  233 
Frauenthal  and  Manning's  table,  788 
Freeman  pasteurizer,  146 
Fremitus,  hydatid,  389 

tactile,  48 
Frenkel's  exercises,  780,  806,  838 
Frenum,  lax,  249 

ulceration  of,  250 
Fresh-air  treatment  of  disease,  214,  423, 

428,  653,  692 
Friction  rub,  435,  456,  494 


Friedreich's  ataxia,  804 

Fright  affecting  mother's  milk,  272 

cause  of  chorea,  841 
Fruit  juices  in  rickets,  241 
Fruits,  diuretic,  546 

in  diet,  327,  328 

raw,  289 
Fuchs-Rosenthal  method,  777 
Fumigation  bj'  calomel,  686 
Fungus,  air-borne,  254 

cause  of  thrush,  253 
Funicular  hernia,  358 
Funnel  chest,  235 
Furunculosis,  592 

of  ear,  610,  615 


Gait,  scissors,  826 
staggering,  743 
steppage,  797,  838 
straddling,  576,  578 
waddling,  799 
Gall-bladder,  obliteration  of,  375 
GaU-stones  in  children,  378 
in  infancy,  120 
passage  of,  376 
Games,  competitive,  333 
Gametocj'tes,  733 
Gangrene  in  measles,  649 
of  appendix,  336 
of  intestine,  323,  335 
of  lung,  442 
of  skin,  601 
of  umbilical  cord,  125 
of  vulva,  580 
Gangrenous  stomatitis,  257 
Gargles,  688 

Gas  bacillus,  a  cause  of  diarrhea,  285 
caused  by  carbohydrates,  201 
eructations  of,  299,  301 
expulsion  of,  313 
m  feces,  195,  210 
Gastralgia,  266 

treatment  of,  267 
Gastric  analysis,  304 
capacity,  186 
contents  of  infants,  193 
digestion,  185,  186,  190 
hemorrhage,  316 
indigestion,  acute,  274 
chronic,  295 
fermentative,  299 
juice,  hyperacidity  of,  304 
in  newborn,  19 
secretion  of,  187 
mucosa,  atrophy  of,  296 
ulcer,  314 

and  pjdorospasm,  311 
in  newborn,  315 
perforation  of,  315 
treatment  of,  315 
Gastritis,  acute,  275,  276 
catarrhal,  276 
diet  in,  278 


INDEX 


875 


Gastritis,  acute,  differentiation  of,  277 
symptoms  of,  276 
treatment  of,  277 
chronic,  295 
diet  in,  298 
differentiation  of,  297 
etiology  of,  295 
pathology  of,  295 
symptoms  of,  296 
treatment  of,  297 
corrosive,  278,  279 
membranous,  276,  277 
suppurative,  276 
ulcerative,  276,  277 
Gastroduodenitis,  279 
Gastro-enteritis,  acute,  279 

diagnosis  Of,  282 
hygiene  in;  283,  285 
pathology  of,  280 
prognosis  in,  282 
symptoms  of,  281 
treatment  of,  283 
caused  by  bacteria,  285 
in  diphtheria,  670 
treatment  of,  285,  287,  294 
with  nephritis,  540 
Gastro-enterostomy,  308 
Gastro-intestinal  diseases,  151,  246 
as  cause  of  death,  56 
caloric  feeding  in,  179 
mortahty  from,  60,  61 
sepsis,  123 
tract  of  infant,  152 
Gavage,  420,  838 
in  infants,  148 
in  meningitis,  814,  819 
Gelatin  for  hemorrhage,   127,   131,  316, 

489 
Generation,  organs  of,  852 
Genitaha,  changes  in,  at  puberty,  854 
cleanUness  of,  575,  579,  582,  584 
manipulation  of,  582,  584 
Genito-urinary  tract,  525 
anomaUes  of,  532 
at  birth,  20,  26 
Geographical  tongue,  248 
German  measles,  653.    See  also  Rubella. 
Gestation,  infection  during,  739 
Gingivitis,  223 
Girdle  pains,  782 
rachitic,  235 
Girl  baby,  care  of  breasts  in,  118 
Girls,  chorea  in,  845 

development  of,  853,  856 
masculine,  514 
pertussis  in,  691,  692 
Gland,  pineal,  516 

thymus,  development  of,  35 
Glands  at  puberty,  859 

ductless,  diseases  of,  493 

in  newborn,  20 
encapsulated,  727 
enlargement  of,  479 
inguinal,  577 

submaxillary,  enlarged,  253 
tubular,  559 


Glands,  tuberculous,  726 
Glandular  extracts,  243,  515 
Glans  penis,  puncture  of,  572 
Glossitis,  desquamating,  248 

obstruction  from,  248 
Glottis,  edema  of,  262,  402 

occlusion  of,  404,  407 

spasm  of,  694 
Glycerin  as  vermifuge,  351 
Glycosuria,  530 
Goat's  milk,  178 
Goitre,  acquired,  508 

at  puberty,  857 

congenital,  508 

exophthalmic,  509 

in  girls,  509 
Gonococci  in  urethritis,  570 
Gonococcus  causing  cystitis,  567 
Gordon  reflex,  825,  827 
Graafian  folUcles,  854 
Graves's  disease,  509 
Gravity  cream,  169 
Green  sickness,  477 

stools,  210,  273 
Grippe,  la,  701.    See  also  Influenza. 

pneumococcus,  702 
Growing  pains,  457,  747,  749,  857 
Growth  at  puberty,  30,  33,  853 

of  child,  30 

limitation  of,  852 
Gruel,  dextrinized,  149 
Guinea-pigs,  inoculation  of,  661,  823 
Gummata  of  liver,  387 

of  spleen,  495 
Gums,  bleeding,  877 

in  scurvy,  765 

lancing  of,  225 

pxunlent  discharge  from,  260 

ulceration  of,  255 


H 

Habit  spasm,  844 
Habits,  unclean,  511,  830 
Hair,  congenital  absence  of,  598 

falling  of,  632 

growth  of,  at  puberty,  854 

scanty,  510 

stumps,  595 
Hand,  accoucheur's,  848 

claw,  796,  804 

trident,  140 

writer's,  848 
Handling  of  babies,  768 
Hardening  of  body,  409,  465 
Hare-hp,  82 

in  idiots,  831 

operation  for,  83 

pathological  anatomy  of,  S3 

treatment  of,  83 
Harrison's  furrow,  235 
Head  in  hydrocephalus,  77 

normal  proportions  of,  34 

of  newborn  infant,  18 

roUing  of,  232 


876 


INDEX 


Headache  in  measles,  652 

periodical,  857 
Hearing,  development  of,  44 

impairment  of,  398,  613 
by  furmicle,  615 

in  newborn,  21 
Heart,  apex  beat  of,  446 

cavities  of,  445 

circumference  of,  445 

compensation  in,  446 

dilatation  of,  458,  504,  635 

diseases  of,  445 

congenital,  447,  450 
functional,  446 
organic,  464 
symptoms  of,  446,  456 

examination  of,  447 

faUure,  669 

hygiene  of,  464 

hypertrophy  of,  455,  663 

in  diphtheria,  668 

in  newborn,  38 

in  septic  infection,  123 

instability  of,  446 

left,  reserve  power  of,  458 

malformations  of,  833 
congenital,  84 

muscle,  weakness  of,  447,  449 

paralysis  of,  669 

rhythm  of,  447 

size  of,  445,  458 

sounds,  reduplication  of,  449,  456 

transposition  of,  454 

tuberculous  lesions  of,  727 

valvular  disease  of,  372 

weight  of,  445 

working  power  of,  448 
Heart's  blood,  bacteria  in,  812,  813 
Heat,  animal,  production  of,  155,  157 

centre  in  the  young,  40 

summer,  and  diarrhea,  331 
Heating  of  house,  26 
Height,  growth  in,  853 

of  children,  30 

normal,  33 
Hematemesis,  314 

serum  treatment  of,  314 
Hematogenic  jaundice,  371 
Hematoporphyrin,  843 
Hematuria,  526 

from  renal  calculi,  555 

from  tumor,  556 

idiopathic,  526 
Hemichorea,  843 

Hemiplegia,  cerebral,  differentiation  of, 
828 

in  purpura,  491 

infantile,  825 

spastic,  107 
Hemoglobin  in  anemia,  476 
in  splenic,  483 

in  blood,  472 

in  rickets,  232 
Hemoglobinuria,  527 

epidemic,  128 

paroxysmal,  527,  528 


Hemolysis,  excessive,  374 

toxic,  478 
Hemophilia,  487 

bleeding  in,  126,  396 
operation  in,  489 
sex  influence  in,  127 
simulated  by  purpura,  491 
transmission  of,  68 
treatment  of,  489 
Hemoptysis  in  tuberculosis,  732 
Hemopoietic  system,  373 
Hemorrhage,  capillary,  478 
from  bowel,  627 
from  nose,  395,  396 
from  tonsils,  399 
from  trivial  cause,  488 
from  ureter  and  urethra,  527 
gastric,  316 
in  adenectomy,  400 
in  jaundice,  120,  370 
in  measles,  647,  650 
in  newborn,  122,  126 
in  scurvy,  763,  764 
in  Winckel's  disease,  128 
into  adrenals,  514 
into  nerve  sheath,  697 
meningeal,  106,  108 
nasal,  665 

rectal,  from  polypi,  365 
spontaneous,  488 
transfusion  for,  127 
umbilical,  125 
within  kidney,  556 
Hemorrhagic  diseases,  487 
Hemorrhoids,  365 
Hereditarj^  ataxia,  cerebellar,  805 

differentiation  of,  805 

etiology  of,  804 

pathology  of,  804 

sensory  disturbance  in,  805 

spinal,  805 
Heredity,  68 

cause  of  nephritis,  542,  547 

of  nem-osis,  301 
in  alopecia,  598 
in  bilious  attacks,  380 
in  chorea,  842 
in  disease,  487,  796,  802 
in  rheumatism,  748 
influence  of,  in  appendicitis,  336 

in  hare-hp,  82 

in  jaundice,  373 

on  brain,  42 

on  height,  30 
mixed,  740 
Hernia,  congenital,  358 
diaphragmatic,  96 
differentiated  from  hydrocele,  98 
femoral,  359,  360 
gangrenous,  361 
in  cretins,  511 
inguinal,  358,  359 
mortality  from,  698 
of  brain,  72 
operation  for,  360,  361 
retention  of,  91 


INDEX 


877 


Hernia,  strangulated,  360,  361 

truss  for,  360 

umbilical,  90,  511 
Herpes,  forms  of,  596 

labialis,  246,  417 

of  nose,  417 

zoster,  597 
Hexamethylenamin  in  meningitis,  818 

in  pyiiria,  532 
Hiccough  in  peritonitis,  338,  352 
Hip-joint  disease,  552 
Hirschsprung's  disease,  92 
Hiss,  leukocyte  extract  of,  612 
Hives,  588 
Hoarseness  due  to  tumors,  406 

in  syphilis,  741,  742 
Hodgkin's  disease,  484 

enlarged  glands  of,  439 
simulated  by  adenitis,  497,  498 
Hookworm,  348 

disease  in  the  South,  341 
treatment  of,  349 
Hookworms  in  moist  earth,  349 

transmission  of,  349 
Horlick's  malted  milk,  328 
Horse  serum,  128,  131,  314,  503,  677 
Hospital  ward,  disinfection  of,  693 
for  observation,  682 
ideal,  213 
Hospitals,  empyema  in,  436 

for  infants,  64,  65 

infant  mortality  in,  212 
Hot  applications  in  dysentery,  292 

compresses,  573 

fomentations,  533 

packs,  546,  637 
House  disease,  414 
Human  blood  serum,  314 
Hutchinson's  teeth,  761 

triad,  745 
Hydrocele,  98 

differentiated  from  hernia,  359 

in  acute  orchitis,  573 

of  cord,  encysted,  359 

sac,  extirpation  of,  99 
Hydrencephalocele,  72,  74 
Hydrocephalus,  acute,  75 

associated  with  hydrencephalocele, 

with  myelocystocele,  103 

with  rickets,  230 
chronic  external,  75 

internal,  75 
congenital,  75 
diagnosis  of,  76 
following  meningitis,  817 
pathological  anatomy  of,  76 
prognosis  in,  77 
simulating  achondroplasia,  139 
treatment  of,  77 
Hydrochloric  acid  as  a  bactericide,  188 

deficiency  of,  197,  298 

in  stomach,  45,  188 
Hydronephrosis,  561 
acquired,  561 
bilateral,  562 


Hydronephrosis,  etiology  of,  561 

intermittent,  562 

puncture  of,  562 

traumatic,  561 
Hydroquinine  in  pertussis,  695 
Hydrotherapy  for  constipation,  329 

in  pneumonia,  429 
Hygiene  at  puberty,  857 

in  diphtheria,  675 

in  gastritis,  298 

in  rickets,  241 

of  chUdhood,  216 

of  infancy,  240,  284 

teaching  of,  67 
Hymen,  imperforate,  103 
Hyperacidity,  gastric,  308 
Hyperemia,  passive,  524 
Hypertrophy,  cardiac,  455 

muscular,  799 

of  pyloric  sphincter,  305 
Hypodermoclysis   in   cholera   infantum, 
295 

in  diarrhea,  286 

in  sclerema,  136 
Hypospadias,  104 
Hypotonus,  774 
Hysteria  at  puberty,  857 

distinguished  from  asthma,  441 

in  tetany,  847 

retention  of  urine  in,  534 


Ichthyosis,  589 

Icterus,  369.    See  also  Jaundice. 

mortality  from,  698 

neonatorum,  118,  369 
Idiocy,  828 

amaurotic  family,  829,  832 

in  spastic  paraplegia,  827 

malformations  in,  831 

manifestations  of,  830 

Mongolian,  symptoms  of,  833 

syphilitic,  831 
Idiotica  thymica,  36 
Idiots,  thymus  gland  in,  502 

training  of,  832 

unclean,  830,  832 
Ileocolitis,  chronic,  320 

symptoms  of,  321 
treatment  of,  322 

difTerentiation  of,  282 
Illegitimacy  as  cause  of  infanticide,  58 

rural  and  urban,  59 
Imagination,  772 
Imbecility,  828 

in  masturbators,  583 
Imitative  instinct,  772 
Immaturity  as  cause  of  death,  54 
Immunization  in  diphtheria,  674,  677,  679 
Impetigo  contagiosa,  591 
bullosa,  601 

differentiated  from  herpes,  597 

simulated  by  varicella,  641 
Incontinence,  fecal,  330,  333 


878 


INDEX 


Incontinence  from  worms,  345 
of  urine,  534 

nocturnal,  536,  571 
refliex,  535 
Incoordination,  test  for,  843 
Incubator,  use  of,  138 
Indicanuria,  198,  530 
Indigestion,  267 

acute  gastric,  274 
carbohydrate,  157 
cause  of  vomiting,  263 
fat,  prolonged,  155 
stools  in,  319 
sugar,  156 
Infant  at  birth,  eyes  of,  26 

genito-urinary  system  of,  20 
normal  appearance  of,  17 
proportions  of,  17 
skin  of,  17 
temperature  of,  21 
boarding  out  of,  166 
deserted,  care  of,  50 
early  training  of,  26 
feeding,  141 

artificial,  178 

and  breast,  combined,  164 
by  percentages,  167,  169 
requirements  of,  152 
materials  used  for,  151 
on  cow's  milk,  141 
on  raw  milk,  146 
problems  of,  152 
foods,  composition  of,  176 
hospital,  modern,  65 
metabolism,  152,  196 
mortality,  50 

among  bottle-fed,  65 
campaign  in  Yonkers,  63 
causes  of,  55 

congenital,  60 
decrease  in  64,  66,  67 
due  to  alcoholism,  59 
during  childbirth,  51 

first  month,  51 
in  census  of  1900,  65 
in  manufacturing  centres,  54,  57 
in  rural  districts,  52,  54 
in  times  of  war,  62 
in  United  States,  51,  66 
influenced  by  social  status,  50, 

52,  53 
Jacobi's  views  on,  64 
prevention  of,  59,  63 
overlying  of,  59 
weight  of,  30 
welfare  stations,  62 
work  performed  by,  42 
Infanticide,  58 
Infantile  muscular  atrophy,  795 

paralysis,    784.      See   Poliomyelitis, 
Acute  Anterior. 
Infarcts  from  emboli,  459 

uric  acid.  111,  528 
Infection,  acute,  followed  by  leukemia, 
479 
by  clothing,  707 


Infection,  cause  of  meningitis,  820 

of  nutritional  disturbance,  203 

during  delivery,  577 

from  oidium  albicans,  254 

of  mouth,  252 

of  skin,  586 

transmission  of,  121 
Infectious  diseases,  specific,  617 
Inflammation,  pseudomembranous,  686 
Inflation  of  intestines,  326 
Influenza,  701 

bacillus  of,  701,  705 

C9ugh  in,  702,  706 

diagnosis  of,  704 

diet  in,  706 

differentiation  of,  704 

endemic,  702 

epidemics  of,  702 

exhaustion  in,  706 

forms  of,  febrile,  704 

gastro-intestinal,  704 
nervous,  704 
respiratory,  703 

heart  in,  705,  706 

morbid  anatomy  of,  702 

mortality  in,  706 

nephritis  in,  703 

pandemic,  702 

pneumonia  in,  703 

skin  rashes  in,  705 

symptoms  of,  702 

treatment  of,  by  drugs,  706 

vera,  702 
Influenzal  meningitis,  812 

serum  for,  814 
Inguinal  canal,  testes  in,  97 

glands  enlarged,  360 
Inhalations  of  steam,  402,  412,  430,  686 
Inhibition,  function  of,  772 
Inoculation,  animal,  663 

intraperitoneal,  823 

smallpox,  714 

with  measles,  642 
Insect  bites,  489,  589 
Insects  in  ear,  607 
Insolation,  810 
Inspection  in  bronchopneumonia,  426 

in  pleurisy,  434 

of  children,  46,  455 
Institution  babies,  breast-feeding  for,  166 

mortality  among,  64,  65 
Intellect,  development  of,  28 
Intercostal  spaces,  rebound  of,  468 
Intertrigo,  590 

Intestinal  indigestion,  chronic,  316 
congenital,  316 

intoxication,  acute,  282 

residue,  303 
Intestines,  smaU,  absorption  in,  190 

strangulated,  336 
Intestines,  abnormalities  of,  191,  323 

absorption  in,  193 

amyloid  disease  of,  334 

atony  of,  326 

atresia  of,  93 

bacteria  in,  195,  289,  332 


INDEX 


879 


Intestines,  diseases  of,  263 
obstruction  of,  94,  334 
congenital,  334 
due  to  diverticulum,  89 
of  infants,  190 
of  newborn,  19,  45 
parasites  in,  341 
peculiarities  of,  190 
perforation  of,  354 
position  of,  326 
putrefaction  in,  198 
tuberculous,  728 
Intoxication,  intestinal,  282 
Intracranial  disease,  840 
Intubation,  402 

in  diphtheria,  682,  683 
in  laryngeal  obstruction,  688 
in  pertussis,  694 
in  thymic  disease,  508 
instant  death  after,  683 
prolonged,  684,  685 
swallowing  after,  683 
tube,  expulsion  of,  683 
Intussusception,  288,  323 
agonal,  324 
diagnosis  of,  324 
differentiation  of,  313 
forms  of,  323 
in  infants,  190 
simulating  peritonitis,  353 

prolapse,  364 
specimen  from,  325 
treatment  of,  surgical,  326 
Inunctions,  oUve  oil,  850 

mercurial,  745 
Iritis,  754 
Iron  in  diphtheria,  676 

in  vicarious  menstruation,  581 
pigments,  478 
reaction,  529 
stored  in  the  body,  158 
Irrigation  by  catheter,  579 
intestinal,  320 
nasal,  393,  664 
of  spinal  canal,  824 
urethral,  570 
Ischiorectal  abscess,  treatment  of,  368 
Isolation  for  vulvovaginitis,  578 

in  varicella,  641 
Itch  mite,  604 
Itching  in  eczema,  587 
in  jaundice,  371 
in  pediculosis,  603 
in  urticaria,  589 
in  varicella,  642 


Jaundice,  369 

acholuric,  congenital,  373 
catarrhal,  120,  369,  370 
due  to  obliteration  of  bile  ducts,  100 
from  gall-stones,  378 
hematogenous,  369,  371,  735 
hepatogenous,  369 


Jaundice  in  cirrhosis,  382 
in  gastroduodenitis,  279 

in  tumor,  388 

in  Winckel's  disease,  129 

obstructive,  369 

of  newborn,  118 

treatment  of,  371 
Jaw  in  rickets,  235 

swelhng  below,  496 
Jaw-bone,  curettage  of,  259 

necrotic,  256 
Jews,  chorea  in,  842 

idiocy  in,  832 
Joint,  flail,  522 
Joints,  affected  by  antitoxin,  682 

ankylosis  of,  758,  761 

blood  effusions  into,  488 

diseases  of,  517 

gonococcal,  522 

fixation  of,  524 

in  purpura,  492 

in  scarlet  fever,  638 

in  septic  infection,  123 

inflammation  of,  635 

suppuration  in,  523 

syphihtic,  761 

tuberculosis  of,  523,  761 
Jugular  vein,  collapse  of,  468 

thrombosis  of,  504 
Jugulars,  pulsation  of,  463 


Kaplan's  test,  776 

Karyokinesis,  479 

Keratitis  in  smallpox,  711,  713 

interstitial,  745 

syphihtic,  743 
Kernig's  sign,  774,  788,  811,  816,  821 
Kidney,  abscess  of,  551 

amyloid,  384 

capsule,  spUtting  of,  551 

congestion  of,  acute,  539 

congenital  cystic,  557,  558 

contracted,  541,  547 

cysts,  558,  559 
bilateral,  561 
treatment  of,  561 

degeneration  of,  623 

diseases  of,  525 

floating,  494 

hemorrhage  from,  526 

inflammation  of,  545 

infection  of,  541 

injury  to,  551 

irritation  of,  545 

large  red  and  white,  547 

malforma,tions  of,  557 

movable,  562 

operations  upon,  566 

pain  in,  551 

pus  in,  551 

pyogenic  infection  of,  551 

tissue,  559,  560 

toxins  in,  545 


INDEX 


Kidney,  tuberculosis  of,  553,  554 

tumor  of,  373,  552,  555 
diagnosis  of,  557 
etiology  of,  556 
treatment  of,  557 
Kidneys  in  diphtheria,  668 

in  influenza,  703 

in  septic  infection,  123 

miliary  tubercles  in,  728 

of  newborn,  20 

uric  acid  in,  554 
Klebs-LoefHer  bacillus,  656,  660,  663,  665, 

677,  679 
Klumpke's  palsy,  110 
Knee-braces,  585 
Kjiock-knees,  237,  244 
Koplik's  spots,  645,  646,  648,  652 
Kyphoscoliosis,  804 
Kyphosis,  781 

in  rickets,  236 

treatment  of,  244 


Labia,  atresia  of,  103 

irritation  of,  576,  578 

ulcer  of,  580 
Labor,  difficult,  conditions  following,  78, 

115 
Laboratory  modification  of  milk,  167, 172, 

181 
Labyrinthitis,  611 

Lactation,  nervous  state  during,  273 
Lactic  acid  bacteria,  145 

in  buttermilk,  174 
in  stomach,  45,  188 
Lactose,  179,  269 

in  mother's  inilk,  270 
Ladd's  percentage  talDle,  171 
Lagophthalmus,  840 
Landry's  ascending  paralysis,  779,  783 
Lanugo,  17 
Laparotomy,  exploratory,  353 

for  ascites,  384 
Laryngismus  stridulus,  404 
treatment  of,  243 
Laryngitis,  acute,  400 

symptoms  of,  401 
treatment  of,  401 

in  measles,  648 

membranous,  648 

submucous,  403 
Laryngospasm,  233,  507 
Larynx,  diphtheria  in,  665 

diseases  of,  400 

edema  of,  400 

flapping  sound  in,  685 

foreign  body  in,  407 

in  girls,  853 

in  scarlet  fever,  635 

membrane  formation  in,  685 

operations  upon,  407 

papillomata  of,  406 

serous  infiltration  of,  402 

spasm  of,  233,  405,  507 


Larynx,  spasm  of,  treatment  of,  405 

stenosis  of,  685 

tube  in,  683 

tumors  in,  406 

ulceration  of,  685 
Lavage,  gastric,  294 

in  infants,  186 
Lead  colic,  839 

line,  839 

neuritis,  839 
Leeches,  403,  611 
Legs,  tenderness  of,  765 
Lemonade  in  pneumonia,  429 
Leptomeningitis,  808 
Leucorrhea,  859 
Leukemia,  479 

blood  in,  480 

lymphatic,  480 

myelogenous,  480 

pathology  in,  479 

splenomyelogenous,  480 

symptoms  of,  480 

treatment  of,  482,  483        _ 
Leukocyte  count  in  appendicitis,  340 

extract,  422,  612 

in  blood,  473 
Leukocytosis,  340,  474,  476 

as  aid  to  diagnosis,  474 

in  atrophy  of  liver,  377 

in  measles,  647 

in  pneumonia,  418 

in  subphrenic  abscess,  380 

in  summer  diarrhea,  281 
Leukopenia,  420,  474 

in  splenic  anemia,  484 

in  summer  diarrhea,  281 
Lice,  forms  of,  603 
Lieberktihn's  glands,  19 
Ligaments  in  rickets,  237 
Light,  leukodescent,  616 
Lime  in  food,  228 

water  in  gastritis,  278 

in  milk  mixtures,  173,  182,  303 
Lipomatosis  interstitialis,  795 
Lio-sucking,  222 
Lips,  diseases  of,  246 

ulcer  of,  247 
Liquids,  swallowing  of,  in  diphtheria,  684 
Lithotomy,  suprapubic,  569 
Lithuria,  528 
Little's  disease,  826 
Liver,  abscess  of,  378 

acute  yellow  atrophy  of,  376,  377 

adhesions  of,  387 

amyloid,  384 

autopsy  findings  in,  386 

cells,  fatty  degeneration  of,  385 

cirrhosis  of,  381,  469 

congestion  of,  372 

cysts  of,  389 

decrease  in  size  of,  377 

diseases  of,  368 

displacement  of,  435 

dulness,  368,  373 

enlargement  of,  373,  384 

examination  of,  368 


INDEX 


881 


Liver,  fatty,  384 

fluctuation  in,  379 

functional  disorders  of,  380 

hydatid  disease  of,  389 

in  diphtheria,  668 

in  jaundice  of  newborn,  118 

in  newborn,  20 

in  syphilis,  742 

iron  in,  858 

location  of,  368 

nutmeg,  372 

red-cell  destruction  in,  478 

secretory  function  of,  192 

size  of,  192,  368 

syphilis  of,  387 

tubercles  in,  728 

tuberculosis  of,  386 

tumors  of,  benign,  389 

malignant,  388 
weight  of,  192 
Lockjaw  in  tetanus,  134 
Lordosis,  236,  799 

of  lumbar  vertebra),  527 
Ludwig's  angina,  634 
Lumbar  puncture,  775,  778 
for  enuresis,  538 
in  hydrocephalus,  77 
in  meningeal  tuberculosis,  725 
in  meningitis,  818,  824 
in  nephritis,  546,  638 
in  pachymeningitis,  810 
in  pertussis,  696 
in  tetanus,  135 
landmark  for,  35 
technic  of,  775 
Lungs,  abscesses  of,  442 
atelectatic,  115,  408 
compression  of,  435 
diseases  of,  414 

expansion  of,  after  birth,  112,  115 
gangrene  of,  442 
in  diphtheria,  668 
in  septic  infection,  122 
necrotic,  443 
of  newborn,  20 
syphilitic,  742 
tuberculosis  of,  721 
Lymph  glands,  abscess  of,  498 

cervical,  tuberculous,  498 
enlargement  of,  484,  495,  497, 

504,  507 
in  scarlet  fever,  630 
suppuration  in,  497 
syphilitic,  743 
tuberculous,  485,  726 
Lymph    nodes,    bronchial,    tuberculous, 
720 
cervical,  swelling  of,  392 
hyperplasia  of,  500 
in  rickets,  230 
inflammation  of,  495 
retroesophageal,  262 
suppuration  of,  635 
Lymphadenitis,  bronchial,  727 
Lymphangioma,  cystic,  of  neck,  87 
Lymphatic  anemia,  blood  picture  in,  485 
56 


Lymphatic  anemia,  differentiation  of,  485 

pathology  of,  485 

treatment  of,  487 
Lymphatics,  suppuration  of,  687 
Lymphocytosis,  474,  479 
Lymphosarcoma,  499 


M 

McBtjrney's  point,  335,  337 
Macroglossia,  86,  249 
Magnesia,  milk  of,  330 
Main  en  griffe,  796,  804 
Malaria,  732 

anemia  in,  736 

blood  changes  in,  733 
test  in,  736 

chill  in,  734 

diagnosis  of,  736 

distribution  of,  732 

double  infection  in,  733 

etiology  of,  732 

forms  of,  chronic,  736 
intermittent,  734 
irregular,  735 

hot  stage  of,  735 

in  tropics,  733 

in  utero,  732 

lesions  of,  734 

nervous  phenomena  in,  735 

parasite  of,  732,  733 

estivo-autumnal,  734 
quartan,  733 
tertian,  733,  734 

paroxysms  in,  733 

pernicious,  733,  736 

Plasmodium  of,  732 

prognosis  in,  736 

prophylaxis  of,  736,  737 

sweating  in,  735 

transmission  of,  733 

treatment  of,  736,  737 
Males,  disease  transmitted  by,  138 
Malformations,  824 

congenital,  72,  82,  698 
of  bile  ducts,  119 
of  esophagus,  88 
of  tongue,  85 

in  idiots,  831 

of  anus,  94 

of  brain,  72 

of  nervous  system,  803 

of  spinal  cord,  72,  100,  778 
Malnutrition,  199,  200 

affecting  thymus,  504 

cause  of  anemia,  475 

prolonged,  763 

with  cyanosis,  452 
Malposition  of  bowel,  95 
Malt  soup,  176,  178 
Maltose,  179 

Mammals,  milk  of,  161,  167 
Mammary  glands  at  birth,  21 

infantile,  swelling  of,  117 
of  mother,  159 


882 


INDEX 


Mammary  glands,  stimulation  of,  117 

Man,  embryo  of,  68 

Marasmus  due  to  fat  indigestion,  268 

fatal,  504 

thymus  gland  in,  36 
Mare's  milk,  178 
Massage,  abdominal,  93,  381,  386 

for  constipation,  329 

in  myotonia,  803 

in  poliomyelitis,  794 
Mast  cells,  473 
Mastication  in  mumps,  699 
Mastitis,  etiology  of,  117 

in  nursing  mother,  164 

of  infants,  117 

treatment  of,  118 
Mastoiditis,  acute,  614 

complications  of,  615 
operation  for,  |)15 

bilateral,  616,  696 

in  otitis,  610 

temperature  in,  615 
Masturbation,  582 

due  to  worms,  345 

etiology  of,  582 

followed  by  chorea,  842 

indican  reaction  in,  530 

in  schools,  860 

manual,  583,  585 

mechanical  prevention  of,  585 

symptoms  of,  583 

treatment  of,  584,  585 
Maternity  hospitals,  120 
Maxilla,  deformity  of,  391 
Measles,  642 

absence  of,  rash  in,  647 

after  diphtheria,  649 

among  the  poor,  651 

at  end  of  uterogestation,  643 

blood  in,  642 

complications  of,  648 

desquamation  in,  646,  647 

differentiated  from  rubella,  655 
from  scarlet  fever,  633 

digestive  system  in,  650 

epidemics  of,  428,  643,  655 

eruption  of,  633,  642,  645 

etiology  of,  642 

eyes  in,  644 

in  early  infancy,  643 

Koplik's  spots  in,  645,  648,  652 

laryngitis  in,  648,  653 

malignant,  647 

membrane  formation  in,  662 

mortality  in,  698 

nephritis  in,  650 

nervous  symptoms  in,  650 

pathology  of,  644 

prophylaxis  in,  428,  651 

relapses  in,  650 

sequelae  of,  648 

severe  forms  of,  644,  647 

simulated  by  serum  rash,  682 

stages  of,  645 

susceptibility  to,  643 

temperature  in,  645 


Measles,  treatment  of,  652 

virus  of,  642 
Meat,  cysticerci  in,  343 
dislike  for,  511 
preparations,  177 
raw,  as  cause  of  rickets,  228 
Meatus,  contraction  of,  104 
Meckel's  diverticulum,  88,  323 
Meconium,  194 
Megaloblasts,  473,  476 
Melena,  complications  of,  132 
etiology  of,  130 
from  gastric  ulcer,  315 
in  cirrhosis,  382 
neonatorum,  129 
prognosis  in,  130 
MeUin's  food,  328 
Membrane,  diphtheritic,  656,  662 

false,  666 
Mendel-Bechterew's  sign,  779 
Meninges,  diseases  of,  808 
Meningitis,  acute,  purulent,  810,  813 
suppurative,  810 

pathology  of,  811 
stimulation  in,  814 
symptoms  of,  811 
treatment  of,  813 
basilar,  820 
carriers  of,  815,  818 
cause  of  hydrocephalus,  77 
cerebrospinal,  814 
contact  in,  815 
dissemuiation  of,  815,  818 
etiology  of,  814 
immunity  to,  818 
mortality  in,  817 
pathology  of,  815 
prophylaxis  of,  818 
serum  in,  818 
symptoms  of,  815 
treatment  of,  818 
epidemic,  814 
following  otitis,  610 
in  mumps,  701 
influenzal,  704,  810 
serum  for,  707 
pneumococcic,  810,  812 
secondary  otitic,  696 
septic,  leukocytosis  in,  474 
simulated  by  gastritis,  277 
staphylococcic,  812 
streptococcic,  810 
stupor  in,  816,  821 
syphilitic,  725 

tuberculous,  75,  724,  728,  819 
diagnosis  of,  823 
etiology  of,  819 
pathology  of,  820 
prophylaxis  in,  824 
symptoms  of,  821 
typhoid,  813 
vertical,  810 
with  diarrhea,  282 
Meningocele,  72,  74 

spinal,  100 
Meningococci,  intracellular,  817,  818 


INDEX 


883 


Meningo-encephalitis,  822 
Menstruation,  851 

and  pylorospasm,  312 

early,  859 

first,  855 

in  chlorosis,  477 

in  nursing  mother,  164 

precox,  581 

value  of,  49 

vicarious,  581 
Mental  brilliancy,  30 

capacity,  transmission  of,  71 

deficiency,  105,  140,  828 

in  masturbation,  582,  583 

development,  retarded,  106 

retrogression,  833 

stigmata,  830 
Mercury,  bichloride,  in  diphtheria,  676, 
686 

in  cirrhosis  of  liver,  383 

in  syphilis,  388,  745 

poisoning  by,  stomatitis  in,  256 
Mesenteric  glands,  tuberculosis  of,  727 
Mesentery,  traction  on,  323 
Mesonephros  attached  to  kidney,  557 
Metabolism,  carbohydrate,  266 

fat,  199 

intermediary,  196,  199,  202,  206 

of  infant,  32,  152,  160 
Metallic  poisons,  256 
Metastasis  from  kidney  tumor,  556,  557 
Meteorism,  208 
Microcephalus,  105 
Microcytes,  473 
Microglossia,  249 

Microlelia,  138.    <Seeafeo  Achondroplasia. 
Micturition,  cramps  in,  553 

normal,  525 
Migraine,  312 
Miliaria,  593 

.Miliary  tuberculosis,  acute,  722 
Milk,  albumin,  173 

bacterial  decomposition  of,  207 

boiled,  289 

cause  of  diarrhea,  331 

certified,  142,  147 

coagulation  time  of,  189 

colostrum,  159,  161 

Commission,  142,  169 

condensed,  150,  317 

crust,  593 

diet,  undernourishment  from,  461 

dispensaries,  63,  67 

dried,  176 

ducts,  bacteria  in,  118 

fat-free,  168,  180,  319 

fat  in,  180,  268 

feces,  contents  of,  195 

formulas,  182 

granules,  195 

human,  1<61 

bacteria  in,  121 

in  dysentery,  292 

infection  of,  60 

inspection,  67 

laboratory,  172 


Milk,  mineral  salts  in,  158 

mixture,  alkalinity  of,  304 
at  different  ages,  182 
constituents  of,  172,  181 
prescription  for,  182 
modified,  147 
modifiers,  177 
pasteurized,  145,  729 

cause  of  scurvy,  764 
peptonized,  148 
preservation  of,  143,  144 
protein,  173 
purity  of,  283,  293 
skimmed,  269 
souring  of,  143,  331 
sterilized,  144,  332 
sugar,  156 

absorption  of,  197 
excess  of,  207 
in  infant  feeding,  179 
tubercle  bacilli  in,  719 
tuberculin  test  for,  729 
withholding  of,  298,  300 
Milk-teeth,  absorption  of,  220 

eruption  of,  217 
Mind  at  puberty,  855 
Mineral  salts,  ingestion  of,  157,  158 

metabolism  of,  198 
Mitral  insufficiency,  463 
regurgitation,  459 
stenosis,  459,  463,  857 
valve  lesions,  458 
Modification  of  milk,  167,  169,  172 
at  home,  169,  172,  180 
in  laboratory,  181 
Modified  milk,  caloric  value  of,  180 
Mole,  hairy,  600,  601 

mahgnant,  601 
Molluscum  contagiosum,  602 
Mongolian  idiocy,  829 

distinguished    from    cretinism, 
512 
Monkeys,  poHomyelitis  in,  784,  786 
Mononuclears,  473 
Monsters,  absence  of  brain  in,  80 

with  ichthyosis,  589 
Monteau  reaction,  823 
Moral  characters,  inheritance  of,  68 

degeneration,  583,  585 
Morbilh.     See  Measles. 
Moro  reaction,  730,  823 
Morse  and  Talbot's  food  table,  176 
Mortality  at  puberty,  856,  857 

from  gastro-intestinal  lesions,  52,  56 
from  summer  diarrhea,  331 
in  appendicitis,  338 
in  children  under  five,  51 
in  diphtheria,  672,  679 
in  fetal  typhoid,  619 
in  infants,  bottle-fed,  51 
during  war,  162 
illegitimate,  58,  59 
of  factory  women,  52 
under  one  year,  56 
in  measles,  651 
in  pyehtis,  566 


884 


INDEX 


Mortalitj^  in  Ritter's  disease,  602 
in  scarlet  fever,  628,  636 
in  smallpox,  717 

tables,  53,  54,   624,  636,   651,  672, 
692,  698 
Mosquitoes,  malaria  transmitted  by,  732, 

737 
Mother,  health  of,  57 

pregnant,  occupation  of,  56 
syphilitic,  388,  746 
"Mothering"  in  hospitals,  65 
Mothers  as  factory  workers,  215 
Mother's  milk,  161 

advantages  of,  208 
antibodies  in,  166,  167 
failing  secretion  of,  162 
fat  in,  200,  268,  303 
food,  elements  in,  184 
.  improvement  of,  239 
lactalbumin  in,  154 
mineral  constituents  of,  158 
protein  in,  154 
pumping  of,  319 
substitutes  for,  178 
sugar  in,  269 
Motor  excitability  in  infants,  43 
functions,  771 
irritation,  821 
responses,  771 
Mouth,  bacteria  in,  686 

breathing,  47,  391,  397,  835 
care  of,  26,  183 
diseases  of,  249 
disinfection  of,  701 
fissures  about,  740 
fungus  in,  253 
hygiene  of,  252,  254 
in  facial  palsy,  840 
in  septic  infection,  122 
inflammation  of,  251 
of  newborn,  19 
necrosis  of,  258 
ulcers  in,  251,  259 
Mucosa,  gastric,  in  rickets,  230 
healthy,  392 
nasal,  395 
Mucous  coUtis,  333 

membrane,  bronchial,  223 
in  infancy,  219 
in  rickets,  233 
in  summer  diarrhea,  280 
nasal,  inflammation  of,  297 
oral,  223,  251,  255 
pigmentation  of,  515 
syphihtic,  742 
tympanic,  607 
patches,  740 
Mucusinstools,  211,  280 
Multiple  neuritis,  835 

non-diphtheritic,  838 
toxic,  839 
Mumps,  699 

compUcations  of,  700 
diagnosis  of,  700 
in  pancreatitis,  389 


Mumps,  isolation  in,  701 

recurrent,  700 

simulated  by  adenitis,  496 

susceptibility  to,  699 

symptoms  of,  699 

treatment  of,  701 

urine  in,  700 
Murmurs,  accidental,  459 

blowing,  457 

cardiopulmonary,  448 

endocardial,  458 

from  debilitv,  449 

functional,  448,  460 

hemic,  475,  477 

in  chorea,  843 

in  school  children,  448 

mitral,  635 

musical,  450 

mj'ocardial,  621 

organic,  462 

presystolic,  459 

pulmonary  systolic,  448 

systolic,  450,  453,  635,  857 

transient,  635 
Muscle  atrophy,  795 

changes  at  puberty,  857 

sense  tracts,  43 

spasms,  806 

tissue,  irritability  of,  302 
Muscles,  facial,  in  chorea,  843 

impaired,  832 

stimulation  of,  802 

trichinae  in,  350 

weakness  of,  237 
Muscular  development,  41 

dystrophy,  progressive,  798 

insufficiency,  470 

weakness,  congenital,  803 
Mustard  bath,  295,  429 

pack,  429 

paste,  412,  421,  429 
Mutilations,  830 
Myelin  in  nervous  sj^stem,  43 
Myelinization  in  spinal  cord,  770 
Myelitis,  779 

compression,  779 

due  to  caries,  treatment  in,  783 
to  Pott's  disease,  782 

paralysis  in,  782 

relapses  in,  782 

transverse,  779 
lesions  of,  780 
picture  of,  782 
symptoms  of,  779,  780 
treatment  of,  780 
Myelocystocele,  101 
Myelocytes,  474,  479 
Myelomeningocele,  101,  103 
Myocardial  insufficiency,  469 
Myocarditis,  464,  469,  650 

diagnosis  of,  470 

diphtheritic,  470 

low-grade,  468 

rheumatic,  756 

stimulation  in,  471 

treatment  of,  470 


INDEX 


885 


Myositis,  757 
Myotonia  congenita,  802 

.  Oppenheim's,  803 
Myringotomy,  611,  637 


N 


N^\i,  600,  857 
Nageli,  experiments  of,  70 
Nail,  claw-sbaped,  47 
Nails,  shedding  of,  632 
Nares,  packing  of,  396 
Nasal  discharge  as  a  symptom,  47 
douche,  394 

passages,  disinfection  of,  393 
occlusion  of,  391 
Nasopharynx,  diplococcus  in,  815 
diseases  of,  391 
in  diphtheria,  664 
in  meningitis,  818 
in  pertussis,  693 
mucopus  in,  438 
Nausea,  postanesthetic,  308 
Neck,  congenital  diseases  of,  86 
cystic  lymphangioma  of,  87 
rigidity  of,  816 
Necrosis  of  finger  or  toe,  521 
Negroes,  rickets  among,  228 
Neisser's  staining  method,  657 
Nematodes,  344 

Neoplasms  a  cause  of  stenosis,  376 
Nephrectomy  for  hydronephrosis,  562 
for  tumor,  557 
for  renal  tuberculosis,  554 
Nephritis,  538 

acute,  convalescence  from,  546 
pathology  of,  542 
prognosis  of,  544 
prophylaxis  of,  545 
treatment  of,  544 
albuminuria  in,  548 
anuria  in,  532 
caused  by  drugs,  542 
chronic,  547 

edema  of  larynx  in,  402 
interstitial,  550 
pathology  of,  547 
parenchymatous,  548 
diet  in,  550 
operation  in,  551 
symptoms  of,  548 
treatment  of,  550 
urine  in,  548 
complications  of,  540,  544 
diet  in,  545 
diffuse,  540 
diphtheritic,  539 
exudative,  543 
fulminating,  543 
gastro-intestinal,  540 
in  diphtheria,  660,  668 
in  infancy,  539 
in  measles,  650 
in  purpura,  492 
in  varicella,  641 


Nephritis,  parenchymatous,  540 
pathology  of,  540 
primary,  540 
puffiness  in,  543 

scarlatinal,  539,  541,  543,  634,  637 
symptoms  of,  543 
syphilitic,  540 
toxic,  539,  542 
transmission  of,  542 
urinary  changes  in,  543 
Nerve,  facial,  839 

roots,  irritation  of,  782 
trunk,  eruption  along,  597 
Nerves,  diseases  of,  835 
peripheral,  770 

changes  in,  836 
stimulation  of,  774,  775 
Nervous  equilibrium,  571 
system,  central,  769 

bacteria  in,  77 
malformations  of,  803 
organic  lesions  of,  830 

development  of,  42,  769,  858 

examination  of,  772 

histological  structure  of,  769 

in  cerebral  palsy,  826 

in  diphtheria,  668 

in  infancy,  219 

in  nephritis,  540 

in  newborn,  21,  769 

in  scarlet  fever,  635 

morphology  of,  769,  771 

of  child,  771 

peculiarities  of,  771 
Nettle  rash,  588 
Neuralgia  in  herpes  zoster,  597 

occipital,  782 
Neurasthenia  at  puberty,  858 
Nem-itis  from  lead,  839 
multiple,  835 
peripheral,  792 
Neurotic  children,  447,  449 
Newborn,  asphyxia  of,  112,  113 
bathing  of,  22 
circulation  in,  18 
deformities  of,  72,  450 
digestive  system  of,  19 
diseases  of,  105 
erysipelas  of,  131 
exfoliation  of,  602 
hematuria  in,  526 
hemorrhage  in,  126,  375 
laryngeal  stridor  in,  405 
leukocytosis  in,  473 
measles  in,  643 
modified  milk  for,  181 
mouth  of,  184 
otitis  media  in,  608 
peritonitis  in,  351 
proportions  of,  17 
respiratory  system  in,  20 
rhinitis  in,  395 
septic  infection  of,  120 
syphilitic  liver  in,  387 
urinary  findings  in.  111 
vomiting  in,  263 


INDEX 


Newman's  mortality  tables,  53,  54 
Night  sweats,  433,  523 

terrors,  330,  523,  752 
Nipple,  bleeding  from,  129 

care  of,  160 

fissured,  283 

injury  to,  220 

shield,  183 
Nipples,  artificial,  care  of,  183,  223,  254, 
283 

rubber,  shape  of,  251 
Nisserian  infection,  578 
Nitrate  of  silver  in  pertussis,  693 
Nitrogen  in  feces-,  195 
Nodules,  rheumatic,  747,  751 
Noguchi  reaction,  744 
Noma,  257.     See  also  Stomatitis,  Gan- 
grenous. 

vulvse,  580 
Normoblasts,  473,  476 
Nose  as  seat  of  diphtheria,  660 

congenital  defects  in,  391 

foreign  body  in,  393 

membrane  formation  in,  662 

passage  of  food  into,  669 

picking  at,  345,  347 

regurgitation  from,  663 

saddle-shaped,  139 
Nosebleed,  395,  462 

in  diphtheria,  662 
Nourishment  by  rectum,  316 

in  typhoid,  625 
Nozzle,  rectal,  use  of,  366 
Nucleo-albumin  in  urine  of  newborn.  111 
Nurse,  clothing  of,  636 

girls,  577,  583 
Nursery,  23,  25 
Nurses,  visiting,  67 
Nursing  bottle,  care  of,  183,  223,  283 

in  diphtheria,  673 

in  myocarditis,  470 

mother,  food  for,  57,  271 
hygiene  for,  159,  240 
Nutrition,  disturbance  of,  202,  203 

faulty,  a  cause  of  scurvy,  763 
of  skin  disease,  593 
Nystagmus,  107 


Obstetric  paralysis,  108,  111,  839 
Obstruction,  intestinal,  94,  299,  334 

of  esophagus,  88 

of  pylorus,  302 

portal,  357 
Occupation  a  factor  in  disease,  815 

effect  of,  215,  216 
Ocular  palsies,  789 
Odor  in  diphtheria,  662 

in  noma,  258 

of  stools,  195,  210,  273 
O'Dwyer's  intubation,  682,  685 
Oidium  albicans,  253 
Oil  in  ear,  611 
Oils,  digestion  of,  200,  304 


Oils,  mineral,  330 

Olive  oil  as  cathartic,  330 

in  infant's  food,  179 
injections,  328 
inunctions,  241 
Olshausen's  operation,  90 
Omphalitis,  124,  125 
Ophthamia,  diphtheritic,  667 
from  vulvovaginitis,  578 
vaccinal,  713 
Opisthotonos,  cervical,  816  • 
in  meningitis,  816,  817,  820 
in  pneumonia,  419 
in  tetanus,  133 
Oppenheim's  myotonia  congenita,  803 
reflex,  770,"  773,  779,  782,  797,  806, 
825,  827 
Optic  chiasm,  hemorrhage  at,  697 

nerve  atrophy,  805,  826 
Oral  cavity,  184,  185 
Orange  juice  for  infant,  147,  183 

in  scurvy,  767,  768 
Orchitis,  570,  573 
in  mumps,  700 
syphilitic,  573 
tuberculous,  573,  859 
Organs  of  special  sense,  21 
Oropharynx  in  uvulitis,  261 
Ossification,  endochondral,  138 

of  bone,  231 
Osseous  canal,  drooping  of,  615 
Osteomyelitis,  acute  infectious,  517 
pathology  of,  517 
simulating  rheumatism,  753 
rarefying,  520 
Osteoperiostitis,  tuberculous,  522 
Osteotomy  in  rickets,  244 
Otitis  media,  398,  840 

acute,  catarrhal,  607 

purulent,  224,  607 
after  diphtheria,  608 
bacteriology  of,  608 
bilateral,  649 
chronic  suppurative,  612 
complications  of,  610,  808 
differentiation  of,  313,  610 
in  bronchopneumonia,  427 
in  diphtheria,  666 
in  measles,  649 
purulenta,  609 
scarlatinal,  635 
suppurative,  614 
symptoms  of,  608 
treatment  of,  611,  637 
Otorrhea,  614 
Outdoor  life  for  infant,  25 

treatment  of  disease,  212 
Overeating,  858 
Overfeeding,  204,  317 

cause  of  fatty  liver,  386 
in  pneumonia,  420,  428 
Overwork  at  puberty,  857 
Ovulation,  853 
Oxidation,  excessive,  198 
Oxygen,  inhalation  of,  138,  422 
for  asphyxia,  114 


INDEX 


S87 


Oxygen  in  pernicious  anemia,  483 
in  pneumonia,  429,  430 

Oxygenation,  deficient,  45 1 
of  blood,  38 

Oxyuris  vermicularis,  344 

Oysters,  infection  from,  617 


Pachymeningitis  externa,  808 
interna,  808 

hemorrhagica,  808,  820 

differentiation  of,  809 
purulent,  808 
serum  in,  810 
symptoms  of,  809 
treatment  of,  810 
Pack,  hot  mustard,  413 
Pad,  vulvar,  580 
Pain  from  renal  calculi,  554 
insensibility  to,  44 
lumbar,  551 
on  urination,  568,  570 
Palate,  391,  831 
Pallor  from  aortic  disease,  456 
in  anemia,  475 
in  heart  disease,  456 
in  pseudoleukemia,  481 
Palpation,  47,  455 
in  pleursy,  434 
of  kidney,  563 
of  spleen,  493 
Palpitation,  cardiac,  462 
Palsy,  bilateral.  111 
cerebral,  792,  824 
Klumpke's,  110 
obstetrical  facial,  111,  839 
ocular,  837 
Pancreas,  diseases  of,  389 
function  of,  45 
in  syphilis,  742 
tuberculosis  of,  390 
Pancreatic  juice,  192,  193 
Pancreatitis,  acute,  389 
Paralysis,  acute  ascending,  783 
cardiac,  507 

diphtheritic,  669,  678,  836 
atrophy  in,  837 
nerve  changes  in,  836 
pathology  of,  836 
prognosis  in,  837 
speech  in,  836 
symptoms  of,  836 
treatment  of,  838 
facial.  111,  611,  839 

obstetrical.  111,  839 
symptoms  of,  840 
treatment  of,  841 
flaccid,  790,  825 

from  spinal  cord  tumor,  101,  103 
in  idiots,  831 
in  meningitis,  822 
in  muscular  atrophy,  795 
infantile,  distribution  of,  789 
Landry's,  783 


Paralysis,  natal,  108 

of  arms  and  legs,  838 

of  extremities,  807,  840 

of  newborn,  105,  106 

of  phrenic  nerve,  837 

postdiphtheritic,  238,  673 

prenatal,  105 

pseudohypertrophic  muscular,  799 

respiratory,  670,  838 
Paranephritis,  551 
Paraphimosis,  572 
Paraplegia  from  birth  injury,  112 

spastic,  826 
Parasite,  malarial,  733 

segmentation  of,  733,  734 
Parasites,  animal,  603 

cause  of  anemia,  478 
of  colic,  313 

in  scalp,  594 

intestinal,  474 

vegetable,  603 
Parathyroid  extract,  850 
Paratyphoid  bacillus,  624,  627 

fever,  etiology  of,  627 
Parotid  gland,  suppuration  of,  700 
Parotitis,     epidemic,     699.       See     also 

Mumps. 
Pasteurization  of  milk,  145,  283 
Pavor  nocturnus,  397 
Pediculosis  capitis,  495,  603 

corporis,  603,  604 

pubis,  603 

with  eczema,  587,  588 
Pelletierin,  344 
Pelvis,  deformity  of,  236,  244 

in  the  sexes,  853 
Pemphigus,  741 

neonatorum,  601 

simulated  by  varicella,  640 

syphilitic,  601 
Penis,  infantile,  516 
Peptonization  of  milk,  148,  273,  285 
Percentage  feeding,  167,  172 
Percussion,  49,  455 

in  lobar  pneumonia,  415 
Pericardial  sac,  obhteration  of,  466 

puncture  of,  467 
Pericarditis,  650 

acute,  465 

from  rheumatism,  465,  467 
prognosis  of,  466 
symptoms  of,  465 
treatment  of,  by  rest,  467 

adherent,  467,  468 

compUcating  endocarditis,  460 

morbid  anatomy  of,  468 

operation  in,  467 

purulent,  466 

treatment  of,  operative,  466 
Pericardium,  tubercles  on,  727 
Perinephritis,  551 

Periosteum,  fibrous  ingrowth  of,  139 
Periostitis  from  infection,  517 
Perisplenitis,  494 
Peristaltic  waves,  302,  307,  312 
Peritoneum,  diseases  of,  351 


INDEX 


Peritonitis,  abscess  in,  353 

acute,  351 

bacUli  in,  352 
etiology'  of,  351 
sj'mptoms  of,  352 

ascites  in,  355 

chronic,  354 

non-tubercular,  355 
treatment  of,  356 

circumscribed,  353,  354 

from  kidney  tumor,  556 

from  rupture  of  appendix,  338 

gonorrheal,  353 

operation  in,  354 

plastic,  353 

pneumococcal,  352,  353 

suppurative,  352 

traumatic,  353 

treatment  «f,  353,  354 

tuberculous,  728 

simulating    Addison's    disease, 
515 
Perleche,  247 
Pernicious  anemia,  478 

blood  picture  of,  341,  478 
color  index  in,  482 
treatment  of,  483 

malaria,  736 
Perspiration,  398,  509 

in  rickets,  232 
Pertussis,  688 

bacilli  in  nasopharynx,  693 

belt  for,  695 

catarrhal  stage  of,  688,  689 

cause  of  prolapse,  363 

compUcations  in,  690.  694,  696 

diagnosis  of,  691 

diet  in,  693 

epidemics  of,  688 

in  diphtheria,  669 

in  females,  691 

in  measles,  650 

in  young  infants,  688 

isolation  in,  692 

hemorrhages  in,  690 

leukocytosis  in,  474 

local  applications  in,  693 

mortality  from,  691,  692,  698 

paroxysms  in,  689,  696 

pathology  of,  689 

prognosis  in,  691 

prophj'laxis  in,  428,  697 

psychic  phenomena  in,  690,   696 

stages  of,  689,  690 

susceptibility  to,  688 

toxin  produced  by,  689 

treatment  of,  692,  694 
vaccine,  697 

whoop  in,  688 
Pes  ca\'ns,  825 

equinus,  800 

vanis,  798 
Petit  mal,  456 
Petroleum  sprays,  737 
Pets  as  carriers,  629 
Peyer's  patches,  288,  290,  617 


Pfeiffer's  baciUus,  701 
Phimosis,  571,  846 

operation  for,  99 

cause  of  cystitis,  567 
of  retention,  533 

treatment  of,  571 
Phlebitis,  septic,  121,  122 
Phosphorus  in  rickets,  242 
Photophobia,  21,  645,  816,  822 
Phthisis,  pneumonic,  724 
Physical  characters,  inheritance  of,  68 

exercise,  excessive,  464 
Pigeon-breast,  37,  229,  235 
Pigment  in  ner\^ous  system,  43 

urinary,  371 
Pigmentation,  514 

due  to  poisons,  515 

malarial,  734 
Pineal  gland,  516 
Pituitary  extract,  516 

gland,  516 
Plane  warts,  598 
Plasmodium  malarise,  732 

hyaline  forms  of,  734 
Plaster  bandage  in  pertussis,  696 
Plastic  operation  for  Erb's  palsj-,  110 

for  spina  bifida,  103 
Plethora  in  newborn,  19 
Pleura,  aspiration  of,  438 

chseases  of,  430 

drainage  of,  436,  437 

hrigation  of,  437 
Pleiu-al  effusion,  differentiation  of,  435 
gravitation  of,  434 
puncture  of,  435 
treatment  of,  436 
Pleurisy,  bacteriology  in,  431 

circulation  in,  433 

convalescence  from,  438 

cough  in,  433 

diaphragmatic,  simulating  appendi- 
citis, 339 

dry,  433 

fever  in,  432 

following  pneumonia,  431 

pain  in,  433 

palpation  in,  434 

pathologj'  of,  431 

percussion  in,  434 

physical  signs  of,  434 

primar^^  432 

purulent,  430 

respirations  in,  433 

serous,  430 

symptoms  of,  432 

tuberculous,  727 
Pleurodj'nia,  757 
Pneumococci,  414,  422 
Pneumococcic  meningitis,  812 
Pneumogastric  nerve,  pressure  on,  447 
Pneumonia,  414 

aspiration,  635,  784,  837 

cause  of  infant  mortalitj^,  63 

differentiation  of,  419 

familj'  tendency  to,  414 

in  diphtheria,  669 


INDEX 


Pneumonia  in  influenza,  703 
in  measles,  649,  653 
leukocytosis  in,  474 
lobar,  414,  669 

clinical  picture  of,  417 
convalescence  from,  423 
crisis  in,  418 
diagnosis  of,  418 
differentiation  of,  419 
in  measles,  649 
morbid  anatomy  of,  415 
physical  signs  of,  415 
stimulation  in,  421 
symptoms  in,  416 

cerebral,  419,  424 
gastro-intestinal,  418 
nervous,  419,  422 
treatment  of,  420 
masked  by  other  diseases,  419 
mortality  from,  698 
postoperative,  407 
prognosis  in,  420 
rheumatic,  752 
right-sided,  339 
treatment  of,  outdoor,  213 
Pocks,  vaccination,  716 
Poikilocytes,  473,  476,  479 
Poisoning,  lead,  839 
Poisons  a  cause  of  hemoglobinuria,  527 

swallowing  of,  262 
Poliomyelitis,  abortive,  784,  786,  791 
acute  anterior,  784 

age  of  onset,  785 
carriers  of,  786,  793 
cellular  infiltration  in,  786 
contractures  in,  794 
deformity  in,  791 
differentiated    from    Erb's 

palsy,  107,  109 
disinfection  in,  793 
dissemination  of,  785 
epidemics  of,  785 
etiology  of,  785 
experimental  study  of,  784 
history  of,  784 
idiocy  in,  829 
immunity  to,  786 
incubation  period  in,  787 
meningitis  in,  788 
muscles  in,  787,  790 
nervous  system  in,  787 
pain  in,  793,  794 
paralysis  in,  788 
pathology  of,  786 
prodromes  of,  788 
prophylaxis  of,  793 
quarantine  in,  793 
recovery  from,  793 
spinal  fluid  in,  788 
symptoms  of,  787 
treatment  of,  793 
by  drugs,  794 
surgical,  794 
trophic     disturbances     in, 
790 
bulbospinal,  791 


Poliomyelitis,  cerebral,  791 
clinical,  783 
diagnosis  of,  791 
differentiation  of,  792 
epidemic,  792,  793 

mortality  in,  792 
infectious  organism  of,  784,  785 
simulating  scurvy,  767 
spinal  fluid  in,  791 
PoUakiuria,  534,  567 
Polyarthritis,  chronic,  758 

in  purpura,  492 
Polychromatophilia,  476,  479 
Polycythemia,  451 
Polynuclears,  473 
Polypi,  364,  365 
Polyserositis,  381 
Polyuria,  534 
Pools,  draining  of,  737 
Porencephalus,  105 
Pork,  inspection  of,  343 
Posterior  nares,  diphtheria  of,  673 
Posture,  significance  of,  47 
Potassium  citrate  in  cystitis,  568 
Pott's  disease,  384,  781 

deformity  from,  552 
differentiated  from  rickets,  236 
Poultices  in  pneumonia,  421 
Poverty,  as  cause  of  rickets,  227 
of  summer  diarrhea,  280 
late  development  in,  855 
Precocity,  psychic,  516 
Precordia,  bulging  of,  455,  458,  462 
Pregnancy,  blood  during,  117 
care  during,  67 
depression  in,  450 
early,  859 

nourishment  during,  239 
Premature  infants,  feeding  of,  182 
Prematurity  as  cause  of  death,  57,  60 
Prepuce,  orifice  of,  571 
Pressure,  intra-abdominal,  358 
intracranial,  808 
intralaryngeal,  685 
Procidentia  recti,  362 
Proctitis,  361 

catarrhal,  361 
gonorrheal,  361,  362 
treatment  of,  362 
Proctoclysis,  saUne,  340 
Progressive  muscular  atrophy,  795 
adult  type,  796 
hereditary,  797 
infantile  spinal,  795 
lateral  sclerosis  in,  797 
neural  form,  795,  797 
peroneal,  797 
spinal,  795 
dystrophy,  798 
atrophic,  801 
hereditary,  801 
infantile,  801 
juvenile,  801 
treatment  of,  802 
types  of,  798 
Prolapse  of  rectum,  290,  362 


890 


INDEX 


Prolapse  of  rectum  from  straining,  290 
in  ileocolitis,  321 
in  summer  diarrhea,  281 
Proportions,  puerile,  852 
Proprietary  foods  a  cause  of  scurvy,  764 
Protein,  digestion  of,  192,  193 
disintegration,  530 
in  cow's  milk,  149 
in  flours,  157 
in  food,  154 

indigestion,  201,  271,  273 
milk,  173 

percentages,  171,  173 
variety  of,  178,  179 
Proteus  fluorescens,  369 
Protozoon  as  cause  of  scarlet  fever,  629 
Pruritus  due  to  fistulge,  367 

to  worms,  345 
Pseudoankle-clonus,  773 
Pseudobacilli,  661 

Pseudocrises  in  pneumonia,  418,  422 
Pseudodiphtheria,  686 
antitoxin  in,  687 
treatment  of,  688 
Pseudohypertrophic  muscular  paralysis, 

798 
Pseudoleukemia,  484 
of  infants,  481,  483 
of  influenza,  481 
of  von  Jaksch,  373 
simulated  by  adenitis,  499 
spleen  in,  482 
Pseudomembrane  in  intestine,  333 

non-adherency  of,  687 
Psoas  abscess,  552 
Psoriasis,  587,  594 
Psychical  changes  at  puberty,  856 

during  pregnancy,  510 
Ptomain  poisoning,  593 
Ptyahn,  185,  191 
Puberty,  851 

breasts  at,  854,  859 
circulation  at,  854,  857 
cough  of,  438 
development  at,  852 
digestive  system  at,  858 
early,  28,  855 

effect  of,  on  cyclic  vomiting,  265 
epistaxis  at,  395 
genitaUa  at,  854 
general  health  at,  856 
glandular  system  at,  859 
growth  at,  30,  33 
heart  disease  at.  463 
morbidity  at,  856,  857 
nervous  system  during,  858 
phenomena  of,  855,  859 
prematirre,  859 
respiratory  system  at,  858 
thoracic  changes  in,  37 
thymus  gland  at,  499 
urinary  disorders  at,  858 
Pulmonary  artery,  abnormal,  452 
tuberculosis,  722 
caseous,  427 
Pulsation,  cardiac,  455 


Pulse,  dicrotic,  621 
frequency  of,  39 
in  childhood,  446 
in  jaundice,  370 
in  myocarditis,  469 
in  pericaditis,  467 
Puncture,  cerebral,  809 

for  laryngeal  edema,  403 
Punctures,  spinal,  823 
Pupils,  dilated,  419 
Purgation  in  cirrhosis,  383 

in  gastritis,  277 
Purin  substances,  529 
Purpura,  abdominal,  492 
differentiation  of,  490 
etiology  of,  489 
fulminans,  490,  491 
hemorrhagica,  491 

typhoid  state  in,  491 
Henoch's,  492 
in  adrenal  disease,  514 
in  splenic  anemia,  483 
pathology  of,  490 
rheumatica,  492,  751 
symptoms  of,  490 
treatment  of,  491 
variolosa,  709 
Pus,  evacuation  of,  523 
fetid,  in  cavities,  530 
from  bronchioles,  424 
from  urethra,  570 
gonorrheal,  577 
in  ear,  609,  696 
in  kidney,  551 
in  nasal  cavity,  395 
in  peritoneum,  352 
in  pleura,  437 
in  stools,  273 
in  urine,  565 
pyogenic,  524 
Putrefaction,  intestinal,  198 
Pyelitis,  563,  564 

due  to  bacteria,  564 

etiology  of,  564 

from  trauma,  564 

prognosis  in,  565 

relapses  in,  566 

symptoms  of,  564 

treatment  of,  by  operation,  566 

by  vaccines,  566 
tuberculous,  565 
Pyelocystitis,  563 
Pyelonephritis,  563,  565 
Pyelonephrosis,  563 
Pyemia  from  joint  infection,  523 

of  joint,  522 
Pyloric  stenosis,  congenital,  308,  310,  311 
hypertrophic,  302,  305 
diagnosis  of,  306 
following  measles,  310 
pathology  of,  306 
recovery  from,  311 
symptoms  of,  306,  310 
in  older  children,  308,  311 
latent,  311 
organic,  309 


INDEX 


801 


Pyloric  stenosis,  treatment  of,  medical, 
309 
surgical,  307,  309,  311 
vomiting  in,  264 
Pyloroplasty,  308 
Pylorospasm,  301 

artificial,  311 

at  menstrual  period,  312 

causes  of,  309,  312 

diagnosis  of,  302 

diet  in,  303 

symptoms  of,  302 

treatment  of,  303,  305 
Pylorus,  dilation  of,  308 

hypertrophy  of,  301 

passage  of  food  through,  187 
Pyonephrosis,  531 
Pyorrhea  alveolaris,  260 
Pyramidal  tract,  773 
Pyuria,  531 

in  pyelitis,  565 


QuAEANTiNE  for  Cerebrospinal  meningitis, 
818 

for  diphtheria,  661,  663,  673,  675 

for  infantile  paralysis,  793 

for  measles,  651 

for  pertussis,  692 

for  rubella,  656 

for  scarlet  fever,  630,  636 

for  vulvovaginitis,  579 
Quincke's  lumbar  puncture,  775 
Quinine  in  malaria,  736,  737,  738 

in  pertussis,  694,  695 


Race  suicide,  57 

Rachischisis,  779 

Rachitis.     See  Rickets. 

Radium  for  angioma,  601 

Ranula,  86 

Rape,  575 

Rash  due  to  drugs,  648 

from  antitoxin,  680,  681,  682 

in  newborn,  26 

scarlatinal,  638,  639 
Ratio,  cardiorespiratory,  417 
Reaction,  agglutinin,  627 

of  degeneration,  774 

tuberculin,  729 
Rectal  tube,  use  of,  626 
Rectum,  ballooning  of,  328 

casts  of,  362 

diseases  of,  361 

early  control  of,  26 

fistula  of,  94 

fixation  of,  364 

polypi  in,  364 

position  of,  363 

prolapse  of,  causes  of,  363 
treatment  of,  364 


Rectum,  worms  in,  344 

Reeducation  movements,  780,  794,  806, 

838 
Reflex  cough,  438 
excitability,  847 
half-voluntary,  696 
irritation,  841 
Reflexes,  abnormal,  773 
examination  of,  770 
in  infancy,  43 
normal,  773 
stimulation  of,  771 
Regurgitation,  264,  268 
Renal  calculi,  554 

composition  of,  554 
impacted,  555 
passage  of,  555 
symptoms  of,  554 
treatment  of,  555 
disease,  pulse  in,  455 
hyperemia,  539 
insufficiency,  558 
tuberculosis,  primary,  553 
Rennet,  clotting  of,  150 

coagulation,  189 
Rennin,  45,  175,  189 
Reproduction,  power  of,  450 
Reproductive  organs,  diseases  of,  571 

system,  853 
Resistance,  lowering  of,  392 
Respiration  affected  by  thymus,  505 
artificial,  in  asphyxia,  114 
audible,  505 

in  bronchopneumonia,  425 
during  infancy,  39 
stammer  of,  405 
Respiratory  centre,  paralysis  of,  116,  790 
stimulation  of,  112,  113 
toxemia  of,  425 
failure,  411 

tract,  anomahes  of,  391 
at  birth,  20 
chronic  catarrh  of,  729 
diseases  of,  391 
in  measles,  648 
in  rheumatism  752 
Rest  in  heart  disease,  470 
Restlessness  in  rickets,  237 
Retro-esophageal  abscess,  262 
Rhagades,  247,  744 
Rheumatism,  747 

acute  articular,  747 

acid  sweats  in,  749 
blood  in,  751 
climate  in,  756 
complications  of,  754,  756 
convalescence  from,  756 
diagnosis  of,  752 
diet  in,  755,  756 
difTerentiation  of,  753 
heart  in,  753,  756 
in  older  children,  750 
joint  effusion  in,  749 
lesions  in,  750,  751 
nervous  phenomena  in,  752 
pain  in,  750,  755 


INDEX 


Rheumatism,  acute  articular,  pathology 
of,  748  _ 
prophylaxis  in,  756 
symptoms  of,  747,  749,  751 

extra-articular,    750 
toxins  of,  749 
treatment  of,  754,  755 
urine  in,  749 

cause  of  endocarditis,  457,  462,  464 

chronic,  758 

etiology  of,  748 

from  malassimilation,  748 

infectious,  748 

muscular,  757 

nervous  theory  of,  748 

recurrent,  748,  750 

simulated  by  scurvy,  767 

treatment  of,  by  baking,  762 

with  chorea,  841 
Rheumatoid  arthritis,  759 
diagnosis  of,  760 
infectious,  759 
treatment  of,  761 
Rhinitis,  acute,  391 

due  to  bacteria,  392 
prophylaxis  of,  393 

atrophic,  395 

chronic,  394 

hypertrophic,  394 

purulent,  395 

simulated  by  diphtheria,  662 

syphilitic,  746 
Rhubarb  in  constipation,  329 
Rhythm,  respiratory,  39 
Ribs,  resection  of,  437 
Rickets,  227 

acute,  245 

adolescent,  245 

anemia  in,  242 

blood  in,  232 

causes  of,  227,  229 

chest  in,  233,  235 

complications  in,  243 

congenital,  245 

convulsions  in,  243 

craniotabes  in,  522 

deformity  in,   229,   233,   235 

dentition  in,  221 

diagnosis  of,  237 

difTerentiated    from    bone    syphilis, 
520 

digestive  disorders  in,  243 

diseases  intercurrent  with,  239 

distinguished  from  cretinism,  512 

due  to  condensed  milk,  150,  153 

etiology  of,  227 

exercise  in,  242 

from  faulty  nutrition,  227 

geographical  distribution  of,  228 

histology  of,  231 

hygiene  in,  241 

in  lions,  228 

mortality  from,  698 

pathology  of,  229 

prognosis  of,  239 

prophylaxis  of,  239 


Rickets,  skull  in,  77,  235,  245 

symptoms  of,  232,  233 

treatment  of,  240,  242,  444 
Rigidity  in  sclerema,  136 

muscular,  848 
"Ring  of  Waldeyer,"  396 
Ringworm,  epidemic,  595 

of  body,  596 

of  scalp,  594,  599 
Ritter's  disease,  602 
Romberg's  sign,  837 
Rosary,  rachitic,  233,  245 
Rotch  on  infant  feeding,  165,  172 
Rotheln,  653.     See  also  Rubella. 
Roux  coccus,  686 

Rubber  nipples,  183,  223,  254,  283 
Rubella,  653 

complications  of,  656 

diagnosis  of,  655 

enanthem  in,  655 

eruption  of,  634,  654 

etiology  of,  653 

rash  in,  654 

simulating  measles,  648 

stages  of,  654 

virus  of,  654 
Rubeola,  634.    See  also  Measles. 
Russian  mineral  oil,  330 


Sacrum,  swelling  over,  101 
Saint  Anthony's  dance,  841 

Vitus'  dance,  841 
Saline  injections,  rectal,  304 

irrigations,  292 

purgatives,  383 
Saliva,  184,  185 

pneumococci  in,  414 
Salivation,  256,  746 
Salt  bath,  850 

fever,  201 
Salts,  soluble,  190 
Salvarsan,  746 
Santonin,  345,  347 
Sarcoma  of  kidney,  555 

of  spleen,  495 

of  testicle,  574 
Scabies,  604 

differentiated  from  pediculosis,  604 

with  eczema,  687,  604 
Scalp,  boils  on,  592 

eczema  of,  587,  588 

infection  of,  72 

lymphangitis,  615 

pocks  in,  640 

ringworm  of,  594 

seborrhea  of,  204 

swelling  of,  595 
Scapula,  loose-winged,  800 
Scarification,  364 
Scarlatina.     See  Scarlet  Fever. 
Scarlet  fever,  628 

albuminuria  in,  634 

as  air-borne  disease,  628 


INDEX 


893 


Scarlet  fever,  cause  of  nephritis,  541 
complications  in,  634 
contact  with,  629,  636 
convalescence  from,  638 
cultures  in,  633 
desquamation  in,  629,  632 
diagnosis  of,  633 
differentiated  from  measles,  648 
-    from  rubella,  655 
from  smallpox,  710 
diphtheria  in,  634 
ear  disease  in,  635 
eruption  in,  628,  631 
etiology  of,  628 
family  predisposition  to,  628 
faucitis  of,  671 
heart  affections  in,  635 
hemorrhagic,  636 
incubation  in,  631 
inoculation,  629 
invasion  of,  631 
leukocytosis  in,  475 
malignant,  636 
membrane  formation  in,  662 
mortality  in,  698 
nephritis  in,  631,  634 
nervous  affections  in,  635 
pathology  of,  630 
pneumonia  in,  635 
prophylaxis,  636 
protozoon,  629 
rash,  630,  631 

simulated  by  serum  rash,  682 
spread  by  milk,  143 
stages  in,  631 
susceptibility  to,  628 
throat  in,  631,  634,  637,  671 
transmission  of,  630 
treatment  of,  636 
virus  of,  628 
white  line  in,  633 
Scars  from  eruptions,  741 
Schaudinn's  spirochseta,  738,  744 
Schick  reaction,  674,  682 
School  children,  anemic,  464 

detention  from,  636,  652,  673,  692, 

845 
hygiene,  29 

life,  as  taxing  child,  29 
nurses,  66 
Schools,  diphtheria  in,  661 
masturbation  in,  860 
measles  in,  644 

medical  inspection  of,  28,  66,  729 
morbidity  statistics  of,  856 
Schron's  capsules,  718 
Schultz's  sign  in  tetany,  849 
Sclera,  pigmented,  374 
Sclerema,  135 

distinguished  from  sclero-edema,  137 
mortality  from,  698 
Sclero-edema,  136 

prophylaxis  of,  137 
Sclerosis  of  spinal  cord,  804 
Scoliosis,  229,  238 

in  muscle  atrophy,  796 


Scoliosis  in  torticollis,  88 
Scorbutus,  763.     See  Scurvy. 
Scrofula  due  to  teething,  224 
Scrotum,  absence  of  testicle  in,  98 

enlargement  of,  573 

in  hernia,  359 
Scurvy,  763 

beef  juice  in,  177 

bone  changes  in,  765 

diagnosis  of,  767 

diet  a  cause  of,  764 

differentiation  of,  238,  767 

etiology  of,  763 

from  sterilized  milk,  145,  147,  332 

fruit  juices  in,  767,  768 

heated  food  in,  764 

hemorrhages  in,  763,  764 

in  nephritis,  540 

morbid  anatomy  in,  764 

raw  milk  in,  764 

simulated  by  hemophilia,  488 

stomatitis  in,  256,  257 

symptoms  of,  765 

tenderness  in,  765 

treatment  of,  767 
Sea  bathing  for  alopecia,  599 
for  miliaria,  593 

food,  589 

salt  baths  242 
Seborrhea,  18,  593 
Secretagogues  in  food,  187 
Secretions,  gastric,  197 

of  testicles,  859 

placental,  117 
Seminal  emissions  in  child,  859 
Senna  for  constipation,  330 
Sense  of  smell,  395 
Senses,  control  of,  829 

development  of,  43,  771 
Sensory  examination,  774 
Separator,  cream,  169 
Sepsis  as  cause  of  hemorrhage,  130 

rash  of,  648 
Septic  infection  of  newborn,  120,  123  ■ 
prophylaxis  of,  124 
treatment  of,  124 
Septicemia,  intestinal,  335 

meningococcic,  818 
Septum,  intraventricular,  464 

nasal,  391 
Serum,  antimeningococcic,  813 

antistreptococcic,  132,  638 

for  influenzal  meningitis,  814 

Flexner's,  818 

human,  316,  489 

injections,  810 

pneumococcus,  422 

rashes,  648,  680,  681,  682 

therapy,  131,  422 

in  cancrum  oris,  259 
in  diphtheria,  677 
in  influenzal  meningitis,  707 
in  scarlet  fever,  638 
Sex  a  factor  in  chorea,  842 
in  pertussis,  692 

doubtful,  104 


S94 


INDEX 


Sex  hygiene,  584 
Sexual  apathy,  571 

development,  514 

disturbances,  514 

instinct,  852 

organs,  abnormality  of,  516 
manipulation  of,  577 
Sheep,  adrenal  gland  of,  515 

thyroid,  desiccated  extract  of,  513 
Shiga  bacillus,  289,  333 
Shingles,  597 
Shock,  emotional,  509 

operative,  380 
Shoes  for  children,  23 
Shoulder,  right,  pain  in,  379 

subluxation  of,  109 
Sick-room  disinfection,  637 

house-cleaning  of,  693 

in  diphtheria,  673,  675 
Side,  fixation  of,  436 
Sight,  defective,  830 
Sinus,  perpetual,  519 

pleural,  438 

thrombosis,  610,  809 
Sinusoidal  current,  794 
Skeleton,  changes  in,  at  puberty,  857 
Skin,  bran-like,  632 

burrows  in,  604 

changes  at  puberty,  857 

clammy,  424 

crusts  on,  591 

desquamation  of,  602,  630,  637 

destruction,  741 

diseases  of,  586 

congenital,  586,  600 
from  teething,  224 
parasitic,  603 

exudate  in,  137,  545 

gangrene  of,  601 

glossy,  839 

hemorrhage  into,  489 

in  Addison's  disease,  515 

in  pseudoleukemia,  481 

in  sepsis  of  newborn,  122 

in  syphilis,  744 

induration  of,  136 

lesions  in  indigestion,  318 

maceration  of,  590 

of  cretins,  511 

of  idiots,  835 

of  newborn  infant,  17 

papery,  590 

pigmentation  of,  375,  509 

rashes  of,  from  drugs,  606 

resembling  armor,  589 

test,  tuberculosis,  297 

trauma  of,  586 

ulceration  of,  101 

white  areas  of,  515 

yellowness  of,  369 
Skull,  bosses  on,  231,  522 

deformity  of,  138 

hot  cross  bun,  235 

malformation  of,  72 

microcephalic,  831,  833 

of  newborn  infant,  18 


Skull,  thin  areas  on,  234 
Sleep  in  childhood,  29 

in  infancy,  23,  160,  770 

importance  of,  461 
Sleeplessness,  397,  439 
Smallpox,  707 

abortive,  710 

cause  of,  708 

confluent,  708,  709 

contagion  of,  707 

crust  formation  in,  712 

differentiation  of,  710 

discrete,  708 

disfigurement  from,  712 

eruption  of,  709 

etiology  of,  707 

hemorrhagic,  708 

history  of,  707 

immunity  to,  707,  717 

inoculation,  714 

modified  by  vaccination,  710 

mortality  of,  717 

pathology  of,  708 

pustules  in,  707,  710 

simulated  by  adrenal  disease,  514 
by  varicella,  641 

symptoms  of,  708 

umbilication  of,  709 
Smegma,  575,  859,  860 
Smell,  sense  of,  development  of,  44 
Snake  poison,  489 
Sneezing,  disease  conveved  bv,  815 
Snow,  CO2,  600 
Snuffles,  397,  741 
Soap-stools,  197,  199,  208,  268 
Social  service  in  hospital,  166 

status  and  infant  mortality,  52 
Sound,  vesical,  569 
Spasm,  esophageal,  827 

habit,  330 

laryngeal,  507 

muscular,  in  infancy,  305 
in  rickets,  233 

myotonic,  802 

of  anus,  366 

of  glottis,  400 

of  tetanus,  133 

pyloric,  308 

tonic,  in  tetany,  847 

vesical,  568 

in  cystitis,  567 

with  dyspnea,  503 
Speech,  absence  of  power  of,  85 

development  of,  44,  771,  830 

exercises,  85 

impairment  of,  84,  398,  805 

nasal,  669 
Spermatic  cord,  thickening  of,  574 

torsion  of,  572 
Spermatozoa,  853,  855 

tubercle  bacilli  in,  719 
Sphincter  ani,  dilation  of,  366 
tonicity  of,  364 

hyperirritability  of,  301 

relaxation  of,  290 

vesicae,  535,  537 


INDEX 


895 


Spina  bifida,  100 

cystica,  779 
occulta,  101 
operation  for,  103 
rupture  of,  100,  101 
Spinal  caries,  552 

column,  fissure  in,  102 
cord,  cavity  in,  803 

compression  of,  781,  806 
degeneration  of,  804 
diseases  of,  778 
inflammation  of,  779 
malformations  of,  72,  778 
of  newborn,  43,  769 
prolapse  of,  101 
tracts  of,  770 
tumors,  806 
fluid,  albumin  in,  776 
bacteria  in,  778 
cellular  elements  in,  778 
dextrose  in,  777 
examination  of,  776 

bacteriological,  778 
chemical,  776 
cytological,  777 
French  method,  777 
physical,  776 
serological,  777 
Fehling's  reduction  of,  777 
findings  in,  817 
pressure  of,  776 
Wassermann  reaction  in,  777 
meningocele,  100 
Spine,  curvature  of,  24,   236,  238,  552, 
857 
development  of,  35 
rigidity  of,  552,  782 
Spirochseta  pallida,  738,  744 
Spleen,  abscess  of,  494 
amyloid,  384 

diseases  of,  mortality  from,  698 
.  enlargement  of,  230,  373,  493 
in  diphtheria,  668 
in  leukemia,  480 
in  malaria,  732,  738 
in  pseudoleukemia,  481 
new  growths  of,  495 
nodular,  495 
rupture  of,  494 
size  of,  493 
syphilitic,  742 
•  tubercles  in,  728 
wandering,  494 
Splenectomy,  483,  502 
Splenic  anemia,  502 

blood  picture  in,  483 
Splenitis,  493 

Splenomegaly,  primary,  495 
Spondylitis  tuberculosa,  728,  781 
Sprue,  253.     See  also  Thrush. 
Sputum,  blood}^,  407 

in  lobar  pneumonia,  417 
rusty,  417 
swallowing  of,  425 
tubercle  bacilli  in,  719 
Stable  fly,  785 


Stagnation  in  stomach,  311 

venous,  315 
Staining,  methods  of,  657 
Staphylococcus  a  cause  of  impetigo,  591 

pyogenes  aureus  in  bone  disease,  517 
Starch,  digestion  of,  149,  176,  193,  197 

in  diet  of  indigestion,  319 

in  infant  feeding,  156,  179 

indigestion,  271 
Stare  in  idiocy,  833 
Starvation  from  indigestion,  199 

in  gastritis,  278 

thymus  gland  in,  504 
Status  lymphaticus,  497,  507 

in  thymic  disease,  502,  504 
treatment  of,  508 
Steapsin,  action  of,  191,  193 
Steno's  duct,  699 
Stenosis,  aortic,  454 

hypertrophic,  308 

laryngeal,  401,  407,  444 

mitral,  459,  463,  857 

of  esophagus,  88 

pulmonary,  451,  453 

tracheal,  507 
Sterilization  of  food,  196 

of  milk,  144,  147,  283 
Sternocleidomastoid  muscle,  trauma  of, 

41,  87 
Sternum,  sinking  of,  766 
Stick  reaction,  730 
Stigmata  of  degeneration,  831 
Stillbirths,  51,  55,  106,  107 

syphilitic,  745 
Stillborn  infants,  kidneys  in.  Ill 
Still's  disease,  758,  760,  761 

simulating  rheumatism,  758 
Stimulation,  faradic,  790 

galvanic,  790 

in  diarrhea,  286 

in  dysentery,  292 

in  gastric  dilatation,  301 
hemorrhage,  316 

sensory,  772 
Stitch  in  the  side,  747 
Stomach,  absorption  in,  190 

ballooned,  299 

capacity  of,  44,  186,  300 

contents,  acidity  of,  187 
in  the  breast-fed,  45 

dilatation  of,  299 

symptoms  of,  299 
treatment  of,  300 

diseases  of,  263 

emptying  of,  45,  190,  311 

hemorrhage  from,  fatal,  316 

inflammation  of,  295 

motor  function  of,  187 

perforation  of,  316 

position  of,  44,  186,  263 

reaction  of,  at  birth,  45 

size  of,  45 

tapeworm  ova  in,  343 

ulcer  of,  314 
round,  477 

washing,  275,  298,  304 


896 


INDEX 


Stomach-tube,  275,  278,  838 
Stomatitis,  aphthous,  252,  253 

catarrhal,  251,  253 

causes  of,  223 

gangrene,  257,  258,  649 
organisms  in,  258 
treatment  of,  259 

herpetic,  252 

in  measles,  649 

mercurial,  388 

mycotic,  255 
.  ulcerative,  255,  672 
Stone  in  bladder,  569 

renal,  527 
Stools  as  index  to  diet,  319 

bacteria  in,  332 

black,  211 

bloody,  129,  315,  324 

bulk  of,  209 

color  of,  100,  210,  273 

disinfection  of,  343,  345 

dry  and  hard,  326 

fat  in,  155 

formation  of,  195 

from  cow's  milk,  195 

green,  269 

hookworm  ova  in,  349 

in  ileocolitis,  321 

in  jaundice,  370,  371,  374 

in  liver  disorders,  381 

in  protein  indigestion,  201 

in  pyloric  stenosis,  306 

in  summer  diarrhea,  281,  284 

normal,  194,  273 

number  of,  195 

odor  of,  273 

of  dyspepsia,  206 

rice-water,  210 

training  concerning,  330 

white,  375 
Straining  at  stool,  327 
Strength,  conservation  of,  428 
Streptococcic  meningitis,  812 
Streptococcus  as  cause  of  scarlet  fever, 
629 

diphtheria,  686 
Stricture  of  anus,  326 
Stridor,  larjTigeal,  401,  405,  406 
Stupor  in  meningitis,  811,  816,  821 

in  nepliritis,  543 
Subarachnoid  space,  drainage  of,  824 
Succus  entericus,  192 
Sucking,  44,  85 

interference  with,  184 
Sudamina,  593 
Suffocation,  666 

due  to  foreign  body,  408 

in  bronchitis,  411 
Sugar,  assimilation  of,  292 

fermentation  of,  173 

fever,  201 

in  milk,  156 

in  percentage  formulas,  173 

in  urine,  530 

indigestion,  269 

intoxication,  201 


Sugar  of  milk,  indigestion  from,  269 
Sugars  as  cause  of  dyspepsia,  206 

digestion  of,  193 
Summer  diarrhea,  279,  281,  284 
pm-gation  in,  286 
infant  mortality  in,  56,  61 
Sunlight,  637 

Suppositories,  cocaine,  286 
glycerin,  328 
use  of,  328 
Suppuration  in  dactylitis,  521 
Suspensory  in  urethritis,  571 
Sutures,  cranial,  ossification  of,  35 
Swallowing,  difficult,  684,  699 
Sweat  ducts,  clogging  of,  593 

glands,  513,  559,  593 
Sweating,  excessive,  237,  723 
Sweats,  night,  732 
Sweets,  excessive  use  of,  320,  385 
Sydenham's  chorea,  841 
Synovitis,  purulent,  522 
Syphilides,  varieties  of,  590,   594,   711, 

740,  741 
Syphihs,  738 

acquired,  738 
albuminuria  in,  743 
bone  changes  in,  742,  745 
cause  of  alopecia,  598 
of  craniotabes,  521 
of  hemoglobinuria,  527 
congenital,  234,  387,  388 
conveyed  by  virus,  716 
early,"'743 

eruption  of,  738,  743 
hereditary,  127,  739 

bone  changes  in,  519 
cause  of  nephritis,  547 
enlarged  spleen  in,  495 
late,  745 
idiocy  in,  832 

infection  in,  sources  of,  738 
joints  in,  744 
lesions  of,  at  puberty,  742 

tertiary,  739,  746 
nervous  system  in,  743 
nutrition  in,  746 
of  bone,  520 
of  liver,  387 
paralysis  due  to,  109 
specific  organism  of,  738 
symptoms  of,  738 
therapeutic  test  in,  297 
transmission  of,  739 

seminal,  739 
treatment  of,  745 
by  mercury,  745 
local,  746 
Syringomyelia,  803 


Tabes,  juvenile,  805 
Tache  cerebrale,  724,  816 
Tachycardia,  447 
f    in  goitre,  509 


INDEX 


897 


Tactile  sensation  at  birth,  21 

I,    sense  tracts,  43,  44 
Taeniae,  341 

echinococcus,  389 
mediocanellata,  342 
nana,  342 
solium,  342 
Talipes  equinovarus,  805 

equinus,  801,  848 
Talking,  backwardness  in,  140 
Tapeworm,  beef,  341,  342 
dwarf,  342 
fish,  342 

expulsion  of,  343 
pork,  341,  342 
segments  of,  343 
stools,  343 
symptoms  of,  343  ■ 
treatment  of,  343 
Tartar,  225,  260 
Taste,  sense  of,  development  of,  44 

in  newborn,  21 
Taxis  for  hernia,  361 
Teeth,  brushing  of,  249,  250 
caries  of,  221,  225 
defective,  222 
deficiency  of,  221 
eruption  of,  185,  220 
extraction  of,  250 
gritting  of,  232,  341,  345,  347 
Hutchinson's,  743,  745 
irregularity  of,  222 
milk,  220  " 
natal,  220,  221 
notched,  745 
permanent,  218,  221 
Teething,  diagnosis  of,  221 

theories  concerning,  217 
Temperature,  high,  cause  of  diarrhea,  331 
continued,  419 
in  appendicitis,  337 
in  bronchopneumonia,  425 
in  cholera  infantum,  294 
in  ileocolitis,  288 
in  infancy,  40 
in  lobar  pneumonia,  417 
in  measles,  645 
in  nephritis,  543 
in  sepsis  of  newborn,  122 
of  newborn,  21 
of  nursery,  23,  25 
outdoor,  maximum  of,  41 
subnormal,  41 
variations  in,  40 
Tendon  transplantation,  802,  828 
Tenesmus,  rectal,  362,  366 
Tents,  treatment  of  wounds  in,  216 
Tenotomy,  802,  828 
Test,  cutaneous,  730 
electrical,  773 
Fehling's,  531 
fermentation,  531 
for  bile,  370 
for  indican,  530 
meal  in  gastritis,  297 
sensory,  774 
57 


Test,  tuberculin,  499,  519,  823 

uric  acid,  528 
Testes,  atrophy  of,  700 

undescended,  97,  98,  572,  859 
Testicle,  cystic  disease  of,  574 

descent  of,  358 

excision  of,  572,  859 

injury  to,  573,  574 

sarcoma  of,  574 

suppuration  of,  573 

tuberculous,  728 

tumors  of,  574 
Testicles  at  puberty,  855 

position  of,  359 
Tetanus,  133 

differential  diagnosis  of,  134 

epidemic,  134 

etiology  of,  133 

symptoms  of,  133 

treatment  of,  134 
Tetany,  846 

among  the  poor,  847 

from  malnutrition,  849 

hygiene  in,  850 

hysterical,  847 

in  rickets,  244 

phenomena  in,  848 

postmortem  findings,  847 

toxic,  847 

treatment  of,  849 
Thermometer,  bath,  22 
Thermometers,  use  of,  361 
Thigh  rubbing,  582 
Thirst  in  dysentery,  290 

in  gastric  dilatation,  300 

in  gastritis,  276,  277 
Thomsen's  disease,  802.     See  also  Myo- 
tonia Congenita. 
Thorax  in  asthma,  441 

of  newborn  iiifant,  18 

size  of,  34,  36 
Threadworm,  341,  344 

treatment  of,  346 
Thrill,  cardiac,  453,  454 
Throat,  cultures  from,  671 

in  diphtheria,  659 

in  scarlet  fever,  631,  634 

inflammation  of,  687 

septic  infection  of,  648 

sore,  rheumatic,  747,  751 

swabbing  of,  675 
Thrombus,  cardiac,  668 
Thrush,  250,  253 

in  chronic  gastritis,  296 

in  cleft  palate,  85 

treatment  of,  255 
Thumb-sucking,  222 
Thymectomy,  508 
Thymic  death,  506 

stridor,  505,  507 
Thymol  for  hookworm  disease,  349 
Thymus  gland,  35,  499 

atrophy  of,  499,  504 
cervicothoracic,  501 
conglomerate,  502 
enlarged,  115,  441,  504 


898 


INDEX 


Th}-mus  gland,  enlarged,   conglomerate 
thoracic,  505 

extirpation  of,  36,  502 
function  of,  36,  501 
h}-perplasia  of,  504 
in  idiots,  502 
in  marasmus.  36 
in  newborn,  20 
lobes  of.  499 
operations  on,  508 
percussion  of,  504 
physiology-  of,  501 
regression  of,  500 
thoracic,  500,  503 
variations  in,  502 
weight  of,  499,  504 
Thyroid  extract  for  adiposity,  516 
for  enuresis,  537 
for  macroglos.sia,  86 
gland,  diseases  of,  508 

enlarged  at  pubertj',  854 
grafting  of,  513 
in  mumps,  700 
in  newborn,  20 
secretion  of,  510 
size  of,  513 
use  of.  249,  513 
Thyroidectin.  509 
Th\Toidectomy,  partial,  509 
Thyroiditis,  510 
Tic  tac,  fetal,  456 
Tinea  circinata,  596 
tonsurans,  595 
Tinnitus  aurium,  849 
Tissues,  waste  of,  154 
Toes,  gangrene  of;  649 
clubbing  of,  452,  454 
necrosis  of,  521 
Toilets,  separate.  578 
Tongue,  diminutive,  249 
diseases  of,  248 
hemangioma  of,  86 
h}-pertrophv  of,  249,  835  I 

in  scarlet  fever,  630,  631  | 

h-mphangioma  of,  86 
of  cretin,  249 
protruding,  248 
strawberry.  634,  656 
swallowing  of,  249 
Tongue-tie,  85 
Tonsillitis,  croupous,  686 
foUicular.  671 

simulating  diphtheria,  659 
in  chorea,  841 
rheumatic.  747,  751 
Tonsils,  chsease  of,  397 

a  cause  of  adenitis,  496 
enlarged,  438,  537 
gangrene  of,  634 
h\-perplasia  of,  399 
in  scarlet  fever.  671 
removal  of,  757 
tumor  formation  in,  396 
Tooth-germ,  destruction  of.  221 
Tooth-sockets,  necrosis  of,  256 
Torsion  of  spermatic  cord,  572 


Torticollis,  41,  757 
congenital,  87 
operation  for,  87,  88 
Toxemia,  cause  of  urticaria,  589 
chronic,  504 
from  worms,  347 
in  diphtheria.  676 
in  pneumonia.  417 
intestinal,  92,  282,  335,  849 
Toxins,  absorption  of,  318 
cause  of  mj'ocarditis,  469 
excretion  oi,  539 
Toxone,  678 

Touch,  sense  of,  development  of.  44 
Trachea,  compression  of,  500,  505 
dilatation  of,  685 
diphtheritic  exudate  in,  683 
Tracheotomy,  402.  403 

diphtheritic  infection  in,  667 
for  foreign  bodj',  408 
in  diphtheria,  682 
in  thymic  disease,  508 
indications  for,  685 
tube,  683 
Training  of  children,  93 
Traits,  hereditan.-,  856 
Transfusion    of  'blood.    127.    129,    131, 

489 
Transillumination  of  stomach.  300 
Transmission  of  characters,  69,  70 

of  disease,  69,  163,  487 
Traube's  space,  460,  466 
Trauma    a    cause    of     intussusception, 
323 
of  meningitis,  820 
of  splenitis,  494 
Tremor,  intention,  826 

muscular,  509 
Trephining  of  skull,  828 
Trichina  spirahs,  350 
Trichiniasis,  350 
Trichocephalus  dispar,  347  • 
Tricuspid  insufficiency,  463 
"Trichter-brust,"  37 
Trismus  neonatorvun,  133 
Trophic  disturbances,  826,  827 
Trousseau's  phenomenon,  774,  848 
Truss  for  hernia,  360 
for  hydrocele,  99 
Trj-psin,  action  of,  191 
Tub  bath  for  infants,  22 
Tube,  rectal.  626 

Tubercle  bacillus,  717,  719,  721.  722 
bo^dne,  718,  819 
cause  of  adenitis,  498 
of  caries,  781 
of  meningitis,  819 
of  peritonitis,  354 
in  skin,  606 
in  urine,  554 
encapsulation  of,  722 
formation  of,  721 
in  kidney,  728 
in  hver,  387 
miliary,  722 

ill  brain,  820 


INDEX 


899 


Tuberculin,  care  in  use  of,  732 
reaction,  499,  519,  823 
tests,  729,  731 
Tuberculosis,  717 

acute,  forms  of,  723 

miliary,      differentiated      from 
typhoid,  624 
alimentary,  718,  720 
at  puberty,  857 
auscultation  in,  724,  725 
autopsy  reports  on,  721 
bone,  518 

bovine,  718,  719,  819 
carriers  of,  720 
chronic,  725 

diagnosis  of,  725 

symptoms  of,  725 
complicating  chlorosis,  477    . 
congenital,  719 
cough  in,  constant,  726 
cutis,  606 
diet  in,  731 

differentiated  from  peritonitis,  355 
emaciation  in,  724 
etiology  of,  717 
general,  722,  726 

and  orchitis,  573 

kidneys  in,  553 
glandular,  727 

bronchial,  726 
hereditary,  719 
in  Addison's  disease,  515 
incidence  of,  721 
latent,  719,  720 

in  measles,  651 
lesions  of,  721 
leukocytes  in,  475 
meningeal,  723 
miliary,  386,  722 
modes  of  acquiring,  720 
of  cervical  lynaph  nodes,  498 
of  intestines,  728 
of  joints,  523 
of  liver,  386 
of  pleura,  727 
pathology  of,  719,  721 
placental,  719 
predisposition  to,  852 
prognosis  of,  728 
prophylaxis  of,  729 
pulmonary,  722 
renal,  553 
tests  for,  729 
transmission  of,  719 
treatment  of,  731 
typhoid  form  of,  723 
ulcerative  papillomatous,  606 
Tuberculous      adenitis,    operation    for, 
499 
meningitis,  819 

chronic,  822 

spinal,  822 
Tumor,  abdominal,  558 
at  root  of  tongue,  403 
bloody,  78 
cerebellar,  805 


Tumor,  cervical,  102 
extramedullary,  806 
fecal,  494 
in  iliac  fossa,  338 
intramedullary,  806,  807 
intrameningeal,  807 
laryngeal,  406 
lumbosacral,  101 
of  brain,  72 
of  kidney,  554 
of  liver,  388 
of  neck,  87 
of  pineal  gland,  516 
of  pituitary  gland,  516 
of  pylorus,  302,  305 
of  rectum,  365 
of  spinal  canal,  100 
of  umbilicus,  89 
pedunculated,  365 
Tumors,  benign  and  malignant,  555 
sessile,  365 
spinal  cord,  806 
Tunica  vaginalis,  358 

hydrocele  of,  98 
Turbinates,  deformity  of,  391 

swelling  of,  394 
Turpentine  stupe,  626 
Tympanites,  2.01,  425,  626 
Tympany,  gastric,  300 
Typhoid  bacilU,  617,  618 

in  cow's  milk,  143 

in  stools,  623 
fever,  617 

abortive,  620 

alcohol  in,  627 

blood  in,  623 

complications  of,  624 

constipation  in,  626 

diet  in,  625 

differentiation  of,  623 

disinfection  in,  617,  625 

etiology  of,  617 

feces,  625 

heart  in,  470 

hemorrhage  in,  627 

herpes  in,  246 

hydrotherapy  in,  626 

in  fetus,  618 

in  older  child,  620 

incubation  in,  618 

infantile,  619 

miscarriage  during,  618 

mortality  in,  624,  698 

pathology  of,  618 

perforation  in,  620,  627 

pulse  in,  620 

relapses,  623 

temperature,  620,  621 

treatment  of,  625 
by  fresh  air,  213 

urine  in,  625 
meningitis,  813 
state,  724 
tuberculosis,  723 
vaccine,  625 
Typhus,  treatment  of,  216 


900 


IXDEX 


Tffelmaxx's  milk  gi-anules,  195,  209 
Ulcer,  follicular,  290,  315 
gastric,  314,  315 
in  rectum,  362 
of  enterocolitis,  287 
of  labia,  580 
of  mouth,  247,  252 
of  skin,  601 
tuberculous,  315 
Ulceration,  corneal,  224 
of  gastric  mucosa,  276 
of  palate,  250 
of  prolapsed  rectum,  363 
of  skin,  101 
of  tongue,  250 
Umbilical  cord,  asepsis  of,  134 
compression  of,  113 
tumor  of,  90 
vein,  bacilli  in,  618 
Umbilication  of  vesicles,  640,  641 
Umbilicus,  diseases  of,  124 
discharge  from,  89 
gangrene  of,  125 
hemorrhage  from,  125 
hernia  of,  90,  95 
infection  of,  120,  128,  522 
Uncinariasis,  349 
Undernom-ishment,  204 
Urachus,  fistula  of,  89 
Urea,  diminution  of,  550 
Uremia,  anmia  in,  533 
hot  packs  for,  637 
in  kidney  cysts,  558 
in  nepkritis,  543,  544 
Ureter,  clots  in,  556 

obstruction  of,  563 
Urethra,  atresia  of,  103 
bleeding  from,  527 
deformity-  of,  104 
irrigation  of,  571 
stone  in,  555 
Urethral  caruncle,  532 
granulations,  532 
Urethi-itis,  diet  in,  571 
gonorrheal,  570 
in  the  sexes,  570 
piu-ulent,  531 
specific,  570 
Uric  acid  crvstals,  528 

infarcts,  111,  533 
Urinalj-sis,  544 
Urine,  alkalinitv  of,  537 

bile  in,  100,  370,  374,  375 

blood  in,  527,  569 

color  of,  375,  526 

dribbling  of,  96,  104,   535,   567,   569 

examination  of,  537 

feces  in,  94 

in  bronchopneumonia,  425 

in  chorea,  843,  846 

in  gastritis,  276 

in  jaundice,  119 

in  nephritis,  540,  548 

in  pneumonia,  418 


Urine  in  renal  tuberculosis,  554 
in  rickets,  232 
in  tj-phoid,  623 
microscopic  study  of,  526 
normal,  525 

acetone  in,  529 
glucose  in,  530 
indican  in,  530 
quantity  of,  525 
specific  gra-\Tity  of,  526 
of  newborn.  111 
pigment  in,  100,  527 
pus  in,  531 

reaction  of,  526,  566,  568 
retention  of,  532 
sero-albumin  in,  527 
smoky  hue  of,  526 
specimen  of,  525 
sugar  in,  530 
suppression  of,  532 
due  to  drugs,  533 
for  ten  days,  544 
tubercle  bacilli  in,  565 
uric  acid  in,  568 
Urobilin,  increase  in,  371 
Urotropin  in  infantile  parah'sis,  794 
Urticaria,  588 

in  purpm-a,  492 
U\Tila,  elongation  of,  260.  438 

puncture  of,  261 
Uvulitis,  260 


Vaccixatiox.  715 

contraindications  for,  717 

eruption  of,  713 

fatal,  716 

history-  of,  714 

mark,  713 

modifying  smallpox,  710 

preferable  time  for,  27 

repetition  of,  716 

transmission  of  disease  bj^  716 

value  of,  717 
Vaccine  therapy  in  cystitis,  568 
in  erysipelas,  132 
in  furunculosis,  592 
in  otitis,  612 
in  pertussis,  697 
in  pyoiThea  alveolaris,  260 

typhoid,  625 

vii'us,  714,  716 
Vaccines,  autogenous,  422,  612,  614,  818 

mixed,  697 

stock,  580,  612 
Vaccinia,  713 

inoculation  with,  714 

in  United  States,  714 

sj-mptoms  of,  715 
Vagina,  inflammation  of,  577 
Valves,  deformitj-  of,  452,  453 
Val\iilar  disease,  acquired,  461 
Vapor  baths,  546 

inhalation  of,  686 


INDEX 


901 


Varicella,  639 

bullosa,  640 

complications  of,  641 

diagnosis  of,  640 

differentiation  of,  641,  711 

eruption  of,  639,  641 

gangrenous,  640 

hemorrhagic,  640 

immunity  from,  639 

scratching  in,  642 

symptoms  of,  639 

treatment  of,  641 
Variola,  707.     See  also  Smallpox. 

hemorrhagica,  708,  710 
pustulosa,  709 

vera,  708 
Variolae  sine  variolis,  710 
Varioloid,  708,  710 

complications  of,  711 

diagnosis  of,  710 

disinfection  in,  712 

eruption  in,  712 

isolation  in,  712 

mortality  in,  711 

pi'ognosis  in,  711 

treatment  of,  712 
Vasomotor  system,  857 
Vegetable  juices  in  scurvy,  768 

proteins,  177    , 
Vegetables,  raw,  infection  through,  289, 

617 
Vein,  umbilical,  obliteration  of,  39 
Venous  hum,  450 

obstruction,  452 
Ventilation,  651 
Ventricle,  hypertrophy  of,  455 

lateral,  distention  of,  75 
Ventricular  septum,  defect  in,  451 
Vermifuge,  344,  347 
Veronal  in  pertussis,  694 
Verrucse  planus  juvenilis,  598 

vulgaris,  598 
Vertebrae,  caries  of,  781 
Vesical  calculi,  composition  of,  569 
operations  for,  569 

spasm,  568 
Virus,  vaccine,  bovine,  714,  715 

humanized,  714,  716 
Visiting  nurse,  57 

physician,  57 
Vocal  cords,  false,  405 
tumors  on,  406 

fremitus,  415,  434 
Voice,  absence  of,  435 

in  diphtheria,  666 

after  emasculation,  854 

change  in,  262,  406 

cracking  of.  854 

nasal,  84,  660 
Volvulus,  335 
Vomiting  after  meals,  296 

as  sign  of  obstruction,  94 

cyclic,  198,  265,  312,  529 

due  to  malformation  of  esophagus, 
8S 

habitual,  263,  303,  307 


Vomiting  in  infancy,  263,  452 

in  meningitis,  816 

in  neurotic  child,  265 

in  pyloric  stenosis,  306 

in  pylorospasm,  302 

in  pyrexia,  264 

in  summer  diarrhea,  281 

in  newborn,  94 

in  tuberculous  meningitis,  821 

of  blood,  129,  315 

persistent,  324 

projectile,  264 

reflex,  264 

stercoraceous,  334 

symptomatic,  263 
Vomitus  of  cholera  infantum,  293 

of  chronic  gastritis,  296 

of  gastric  indigestion,  274 
von  Jaksch,  pseudoleukemia  of,  481 
von  Pirquet  reaction,  322,  353,  521,  523, 

730,  731,  744,  823 
Vulva,  excision  of,  580 

gangrene  of,  580 
Vulvovaginitis,  575 

cause  of  peritonitis,  353 

epidemic,  576 

gonorrheal,  575,  578 

treatment  of,  579 


W 


Walking,  24,  42,  106 

chair,  794 
Wart-pox,  710 
Warts,  597.     See  also  Verrucse. 

contagious,  602 

removal  of,  598 
Wassermann  reaction,  388,  520,  521,  523, 

591,  744,  777 
Waste,  elimination  of,  153 
Wasting  from  melena,  131 
Water  as  a  diluent,  149 

bed,  818 

boiling  of,  617 

contaminated,  289 
worms  from,  348 

in  ears,  607 

in  fevers,  712 

infant's  need  of,  153,  280,  428 
■  ingestion  of,  31,  153,  283,  328 
excessive,  534 
Weaning,  162,  239 

during  teething,  219 

feeding  after,  183,  317 

in  summer,  283 

partial,  164 

temporary,  164 

time  for,  163,  239 
Weichselbaum's  diplococcus,  814 
Weight  chart,  32 

em've,  decline  in,  205 

fluctuations  in,  198 

gain  in,  152,  853 

increased  by  carbohydi'ates,  157 

loss  of,  159,  207,  294,  317 


902 


INDEX 


Weight,  normal.  33 

of  boys,  30  .    . 

of  infants,  30,  31 

scales,  33 

significance  of,  323 

stationary,  31,  33,  268 
Weil's  disease,  371 
Wet-nurse,  165,  268,  269,  271 

infection  of,  740 

necessity  for,  285 

selection  of,  166 

syphilitic,  164,  746 
Whey,  174,  175 

cream  mixtm'e,  285 

in  gastro-intestinal  diseases,  176 

proteins,  202,  272 
Whipworm,  347,  348 
White  line  on  finger,  656 
Whooping-cough,  688.   See  also  Pertussis. 
Widal  reaction,  420,  619,  623,  624 
Will,  weakness  of,  860 
Winckel's  disease,  128,  130,  371,  527 
Winking,  optical  reflex  of,  43 
Wolffian  body,  557 
Worms,  intestinal,  341 

among  the  poor,  341 
treatment  of,  345 

pin,  344 

round,  341,  346,  347,  378 

seat,  344,  582 


Worms,  thread,  341,  344 
Wounds,  diphtheria  in,  667 
Wrist,  broad,  in  rickets,  236 


X 


X-RAYS   in   diagnosis,    435 

of  enlarged  thymus,  508 
of  foreign  body,  408 
of  renal  calculi,  555 
of  spinal  disease,  87 
of  torticollis,  87 

in  ear  disease,  615 

in  enlarged  lymph  nodes,  439 

in  locating  colon,  93 

in  lymphatic  anemia,  487 

in  pericarditis,  466 

in  psoriasis,  594 


Yellow  atrophy  of  liver,  376 


Zappert's  records,  793 
Zygoma,  sign  over,  849 


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